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The Medicare Secondary Payer (MSP) Act has expanded the scope of workers’ compensation and liability claims beyond each individual state’s law concerning Medicare compliance. It also extends responsibility to plaintiffs’ attorneys, claimants of state, as well as self-insureds. As a result, it is vital to realize who is making payments for medical benefits on both accepted cases and disputed cases.
There are a variety of ways that your organization can consider the MSP act and still be in compliance with its new regulations. It is advised to begin with conducting a comprehensive review of each claim prior to choosing a course of action.
When determining Medicare’s future interest in a settlement, an entity will generally not provide a future medical allocation while documenting that no future medical allocation was provided.
Options for considering Medicare’s future interest in a settlement include:
- Commutation approach – takes into consideration what to reasonably expect to compensate for future medical expenses after the date of the settlement as a result of a work-related injury or disease.
- Compromise approach – takes disputes on the case into consideration and is generally computed by an MSA (Medical Savings Account) that funds an accepted portion of the claim or an MSA that is based on a percentage of the settlement.
- Seeking CMS (Centers for Medicare and Medicaid Services) approval – A voluntary process in which parties involved in the case are not required to undertake. This process typically leads to an overfunded MSA or an MSA that funds all possible treatments rather than probable or expected treatments.
Entities can address Medicare’s reimbursement requests on payments made by asking for documentation confirming that the request is related to the case and to ensure that reimbursement is indeed owed. At times, Medicare may ask for something that is not related to the claim itself. If it is a possibility that Medicare wrongfully collected on the case, the entity should investigate/appeal the request and search for methods to reduce the amount they are asking for or they have already taken from the case.
When reviewing these cases, it is imperative to maintain the mindset that the burden of proof should lie with Medicare.
The Medicare Secondary Payer Recovery Portal (MSPRP) is a tool developed by CMS several years ago to allow for online access to their recovery processes. On Thursday August 16th, CMS hosted a Medicare Secondary Payer Recovery Portal (MSPRP) Overview Webinar to discuss some recent enhancements to the system.
To reduce the number of calls that they receive regarding the status of their cases, one of the improvements made is the new “Letter Activity” tab. This tab allows insurers and their authorized representatives the ability to view the status of their incoming and outgoing correspondence on cases.
Another new feature allows both the insurers and beneficiaries (and their representatives) the ability to now request electronic letters including Electronic Conditional Payment Letters (e-CPL).
NuQuest looks forward to utilizing these enhancements to assist our clients in what we are hopeful will be a more efficient conditional payment recovery process and will continue to monitor the efficiency and accuracy of these recent changes.
NuQuest strives to save our clients’ money, even years after the original settlement. One example is how a claim that was recently amended saved our client $567,706. Although the original CMS approval in January 2015 was for $780,736, a CMS Amended Review was requested by our client, due to a change in the treatment plan. Our updated review reduced the claim amount to $213,030, and the amended proposal was approved by CMS.
Our clients choose NuQuest as their trusted Medicare and MSP Compliance partner because we have a reputation for honesty and dependability. Over the years, we have assembled a core of specialists with industry-leading expertise in the areas of medicine, law and benefits. Contact us today to discover the NuQuest difference.
On 8/16/2018 at 1:00 PM EDT, the Centers for Medicare and Medicaid Services (CMS) will be presenting an “Overview Webinar” on its Medicare Secondary Payer Recovery Portal (MSPRP). The MSPRP is a useful tool in assisting parties regarding the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC)’s collection of conditional payments. Click here to be directed to the notice.
Once BCRC has been notified of the settlement, judgment or award (TPOC), BCRC will generally issue Medicare’s final lien with respect to the claim’s settlement.
This process above should not be confused with the Commercial Repayment Center’s (CRC) separate collection for Ongoing Responsibility of Medical (ORM) reporting. CRC’s notice and initial determination process is not a final lien from Medicare. If ORM has been reported or terminated, CRC may issue a separate collection against the carrier or self-insured based upon the ORM reporting. In certain circumstances both companies CRC and BCRC may initiate collection over the life of the claim.
It is important to remember that, at this time, the MSPRP only provides information with respect to payments made under Medicare Part A and Part B. There is yet to be a mechanism requiring CMS to advise its Part C and Part D partners that it has been notified of a TPOC or ORM reporting, legislators are trying to impact this issue through the Provide Accurate Information Directly Act, “PAID Act”, H.R. 5881.
A follow up will be posted after the 8/16/18 presentation.
Medicare has formulated a response to the opioid epidemic by altering the authority and ability of Medicare Advantage Plans and Prescription Drug Plans to implement drug management programs. This change in the regulations issued by Medicare is the product of the Comprehensive Addiction and Recovery Act of 2016 (CARA) which authorized Medicare prescription plans to establish drug management programs beginning 1/1/2019. This means as early as 1/1/2019, an MAP or Medicare Prescription Drug Plan will have the ability to identify “at-risk beneficiaries” and implement drug management programs for those individuals. This also means a prescription provider may reach out to a prescriber or beneficiary regarding such management programs. It is important that prescribers and beneficiaries are educated that such programs may be used by their Medicare insurance provider in the future.
We will keep you posted as the war on opioids further develops.