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Agenda Introductions – Ginger Susman General Update – Pete Flowers & Ellen Relkin Medicare Lien Resolution Update – Bob Marcino Medicaid Lien Resolution Update – Bob Marcino Private Lien Resolution Update – Bob Marcino Closing and Q&A – Ginger Susman & Bob Marcino
Introductions Pete Flowers, Esq. Meyers & Flowers Ginger Susman, Esq. President, Providio Ellen Relkin, Esq. Weitz & Luxenberg Bob Marcino, Esq. General Counsel, Providio
General Update Enrollment period opened 1/16/15 Communications regarding lien process ongoing Town halls, communications, this webinar Lien Situation is Fluid – Mass Tort Lien Resolution Processes Differ in many ways from Single Event Lien Resolution Lien amounts &/or applicable program terms will not be definitively known for all lien types prior to close of enrollment period but you will have strong understanding of the framework where most important: Medicare model amounts Other gov’t lien terms Medicaid program terms Private lien terms (non-LRP) Medicare Advantage terms Private lien terms (LRP)
Lien Resolution in Stryker MedicareMedicaid Other Government Medicare Advantage Private MSA OBLIGATIONS & REQUIREMENTS
4 Different Lien Types To Be Resolved Medicare: VOE* and Group Model Resolution Method Medicare Part C: VOE and LRP (lien resolution programs) “Other Government” Liens addressed individually Medicaid: VOE* and Offset and Holdback agreements by State * VOE means Verification of Entitlement to see who is covered Private Liens also being addressed in LRPs above, and in some cases individually
Medicare Group Resolution Model Group modeling is an alternative resolution approach for Medicare liens available only in mass torts De facto method in large consolidated settlement programs Certain rules apply and are non-negotiable including no opt-outs, no review of individual CPLs, and no appeals Why do the vast majority of mass tort settlement programs utilize group resolution modeling of Medicare liens? Good lien reductions for overwhelming majority of claimants Provides certainty on program terms prior to enrollment Enables significantly faster clearance In Stryker, no need for Medicare Set Asides Fair, group-oriented approach Downside of modeling? There are always a small number of claimants who are disadvantaged by the model – bell curve dynamics
Medicare Resolution Model
Medicare Group Model (notes) The $19,130 model obligation for revisions includes additional compensation beyond base awards for: Controlled osteotomy Femur fracture requiring osteotomy with cabling Femur fracture during revision (or re-revision) requiring cabling but no osteotomy Repair/reattachment of abductor muscles Dislocations Includes future care. No Medicare Set Asides required
Medicare Group Model – Example 1 Medicare paid the whole way Claimant was on Medicare prior to and after revision and had no other health coverage Result: Claimants pays the full Medicare model amount of $19,130 Approximately 70% of Medicare entitled Stryker claimants fall into Example 1
Medicare Group Model – Examples 2 & 3 Where Medicare paid for pre op and revision itself Example 2 Claimant on Medicare prior to and for revision, BUT a group health plan (“GHP”) asserts a lien for follow up care beginning 4 months after the revision. The GHP lien, after relatedness audit and negotiated reduction totals $3,250. Result: Claimant pays Medicare $10,353 plus the GHP lien of $3,250 for a total of 13,603. Example 3 Same as Example 2 except resulting GHP lien higher at $12,225 due to more extensive and expensive follow up care. Result: Claimant pays Medicare the same $10,353 plus the GHP lien of $12,225 for a total of $22,578. Approximately 5% of Medicare entitled Stryker claimants fall into Examples 2 and 3
Medicare Group Model – Example 4 & 5 Where Medicare paid for follow up and future care Example 4 Claimant was on Medicare but not until 4 months AFTER their revision. GHP asserts a lien for the revision at $32,000. After audit and negotiated reduction, the GHP lien comes down to $23,360. Result: Claimant pays the GHP lien of $23,360 plus Medicare model lien amount of $8,776 for a total of $32,136. Example 5 Same as Example 4 but GHP final lien is less at $9,100. Result: Claimant pays the GHP lien of $9,100 plus Medicare model lien amount of $8,775 for a total of $17,875. Approximately 5% of Medicare entitled Stryker claimants fall into Examples 4 and 5
Medicare Group Model – Example 6 Where Medicare Part C paid the whole way Claimant was on Medicare but had a Medicare Part C plan (also known as Medicare Advantage) before and well after their revision. The Medicare Part C plan asserts a lien of $28,500. After audit and negotiated reduction, the Part C lien is $17,100 Result: Claimant pays the Part C lien of $17,100 and pays Medicare nothing Approximately 30% of Medicare entitled claimants will have had a Part C plan at some point before their revision or after. About ½ of them fall into this example where Medicare Part C paid the whole way.
Medicare Group Model – Lesser Amounts
Medicaid Lien obligation by injury varies by State – no model Average holdback range: 33% - 40% “offset” (i.e., reduction for attorneys fees/costs) Most states have 20% holdback (max % of gross settlement) Some states have higher holdback – highest is 35% of gross Review the communication sent by leadership for details of recent program terms on a state-by-state basis Medicaid agencies will not agree to terms until after VOE commences This will occur when all enrolled claimants are identified upon close of enrollment period.gross
Other Government Liens gross Examples: Tricare, VA, FEHBA No program terms Providio will negotiate directly with other government lien holders You will be asked to provide Providio with relevant correspondence
Medicare (Parts C)/Medicare “Advantage” The Medicare Advantage process of entitlement verification (VOE) will be accomplished through a number of lien resolution programs (LRPs) Rawlings LRP Confirmed Discussions in process with Gibson Sharps/Kim West group If claimant’s Medicare Advantage plan is not part of one of the LRPs, then Providio to handle one-by-one, directly with the Part C plan.
Rawlings LRP Terms LRP in place with Rawlings Rawlings estimates they will represent 25-30% of GHPs nationwide for Stryker Current list of committed Rawlings PLRP GHPs (in process of adding more): Aetna, Inc. AmeriGroup AvMed, Inc. BCBS Association BCBS South Carolina BCBS Vermont CIGNA HealthCare, Inc. Coventry Health Government Employees Health Assoc. (GEHA) Group Health Cooperative (including KPS Health Plans) Health Care Service Corporation, i.e. BCBS TX, IL, NM, OK HealthNow New York, Inc. Johns Hopkins Healthcare Priority Health WellCare Health Plans (Medicaid Plan) Lien obligation based on actual claims paid: Automatic 40% “offset” (reduction for attorneys fees/costs) OR Maximum of 25% of gross settlement* Claimant pays whichever is less Anti-subrogation state laws apply State-based made whole laws do not apply
Private Health Insurance gross The LRPs for Medicare Advantage will be used to resolve private liens too Same terms will apply Claimants automatically enrolled in whichever LRP program that applies unless they opt-out by the “opt-out deadline” A claimant letter regarding the lien resolution process and associated fees will be coming soon and the letter will contain an opt-out form for any claimant desiring to have their private liens handled individually Opt out deadline to be announced If a firm has already elected to use Providio for private lien resolution through the LRPs that election does not obligate individual claimants, they can still opt- out. For private liens with any GHPs not part of the LRPs there will be no program terms Providio will negotiate directly on an individual basis with such GHPs
Frequently Asked Lien Questions What if I already received a CPL from Medicare for a client and it’s less than the model amounts? Is there an appeal or opt-out process? If my client has a re-revision for which s/he obtains a future award, does this round of lien resolution cover everything or will s/he owe more for liens with the second compensation award? How will lien resolution be handled for claimants who are medically unable to be revised? Will I know my clients’ lien amounts prior to enrollment? What if Broadspire paid for the revision or I have proof that my client paid out of pocket?
Frequently Asked Lien Questions What is the timeframe for overall lien resolution and how should I set client expectations? How are ERISA plans handled? What if my client’s Medicare Advantage or other private health plan is not covered by an LRP? Do I still need to consider Medicare Set Asides for any of my clients or does the Medicare model process take care of that? What information should I send to Providio to make sure they are working my clients’ liens?
Cost of Providio Lien Services* Medicare (Parts A & B)/Medicaid Lien Resolution -- Current Revisions/Care and Future Revisions 1 lien - $350/claimant 2 liens - $600/claimant Rawlings LRP Lien Resolution (including Medicare Advantage (Part C)) – Current Revisions/Care and Future Revisions $212/claimant** Other LRP Lien Resolution (including Medicare Advantage (Part C)) – Current Revisions/Care and Future Revisions TBD Non-PLRP Private Lien Resolution – Current Revisions/Care and Future Revisions 1 lien - $850/claimant Additional liens - $250/lien Other Governmental Liens – Current Revisions/Care and Future Revisions 1 lien - $850/claimant Additional liens - $250/lien ** Providio’s Rawlings LRP total lien resolution fee is $425/claimant. Rawlings has agreed to reimburse 50% of this in recognition of the value the PLRP program brings to the overall process, and to help defray the lien resolution cost to plaintiffs. * All VOE fees are being paid out of the MDL and NJ common benefit so they’re not listed here as direct claimant cost.
Closing and Q&A Communication protocol for maximum lien reductions in most efficient manner For urgent questions, please us at If you missed the deadline to select Providio for your private lien resolution but would like to utilize our services, please your request to us at Providio is also the QSF administrator for Stryker. Information relevant to distribution coming later (early summer) For urgent questions, please us at Q&A