1 NY Chapter - RIMS MMSEA Reporting & MSP Compliance

2 Medicare Compliance - Evolution Passed in 1980: 42 USC 1395y and 42 CFR 411 Passed in 1980: 42 USC 1395y and 42 CFR 411 Legislative Intent: Medicare will always be a “Secondary Payer” if a primary payer exists Legislative Intent: Medicare will always be a “Secondary Payer” if a primary payer exists Primary Payers include: Workers’ Compensation, Liability, Auto No Fault, USL&H, Jones Act, and Group Health Primary Payers include: Workers’ Compensation, Liability, Auto No Fault, USL&H, Jones Act, and Group Health In July of 2001, CMS introduced the MSA Review and Approval process for certain WC settlements In July of 2001, CMS introduced the MSA Review and Approval process for certain WC settlements In December of 2007, SCHIP Extension Act was passed into law and affects claims that involve payments, settlements, judgements, awards with Medicare beneficiaries In December of 2007, SCHIP Extension Act was passed into law and affects claims that involve payments, settlements, judgements, awards with Medicare beneficiaries

3 Why the Mandatory Insurer Reporting? Primary Purpose – Enforce MSP Compliance RequirementsPrimary Purpose – Enforce MSP Compliance Requirements CBO Assessment – plans to collect $1.1 Billion in fines from “Primary Payers” for non-complianceCBO Assessment – plans to collect $1.1 Billion in fines from “Primary Payers” for non-compliance CIVIL MONEY PENALTY FOR FAILURE TO REPORT: $1, per day per claim They intend to use the data to collect past paymentsThey intend to use the data to collect past payments They intend to use the data to stop erroneous future paymentsThey intend to use the data to stop erroneous future payments

4 SCHIP Extension Act of 2007 SCHIP makes NO CHANGES in the WC MSA Review and Approval Program SCHIP is a separate and distinct program that runs in parallel with your WC MSA Program SCHIP brings an additional step requiring mandatory reporting May change the way you manage your Medicare risk

5 Conditional Payments Requires that all Medicare “liens” are reimbursed in a timely mannerRequires that all Medicare “liens” are reimbursed in a timely manner If not paid by claimant/plaintiff in 60 days post-settlement become the responsibility of the primary payerIf not paid by claimant/plaintiff in 60 days post-settlement become the responsibility of the primary payer US v. HarrisUS v. Harris Medicare can recover double damages plus interest and attorney feesMedicare can recover double damages plus interest and attorney fees Projected Trends with Conditional Payments - in 2010, 2011 & forwardProjected Trends with Conditional Payments - in 2010, 2011 & forward Requires that “adequate consideration” of Medicare’s interest is shown in all settlements involving a Medicare Eligible claimant/plaintiffRequires that “adequate consideration” of Medicare’s interest is shown in all settlements involving a Medicare Eligible claimant/plaintiff Absent an allocation Medicare can recover the entire settlement amountAbsent an allocation Medicare can recover the entire settlement amount CMS - Past Recovery & Future ProtectionCMS - Past Recovery & Future Protection

6 Integrated Solution - Steps MSP Compliance & SCHIP Reporting Step One: Identify - MQF Step Two:Satisfy – CPR & LNS Step Three:Allocate Step Four:Report - MIR

7 G&L Contact Information Duke T. Wolpert, MSI, SCLA Vice President of Strategic Services Gould & Lamb, LLC 101 Riverfront Blvd., Suite 100 Bradenton, FL Ext