Learn more about the Conditional Payment Recovery Process presented by Rasa Fumagalli, JD, MSCC
Rasa Fumagalli’ s webinar presentation on Monday, April 25th outlined the various changes that came about as a result of the implementation of the Strengthening Medicare and Repaying Taxpayers Act of 2012. These changes include: the three-year Statute of Limitations for conditional payment recovery, the establishment of recovery thresholds in liability cases, a new direct right of appeal for applicable plans, as well as the ability to secure final conditional payment information in certain settlements. We will also discuss the partial transition of recovery work from the Benefits Coordination and Recovery Center (BCRC) to the Commercial Recovery Center (CRC), as well as the initiation of conditional payment recovery in claims with Ongoing Responsibility for Medicals. Given the impact of these changes, it is important that all Medicare compliance programs account for them.
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Combining MSAs with Drug Regimen Reviews provides a complete clinical review of future injury–related expenses (1 hr)
Since MSA guidelines issued in June, 2009, indicated that CMS would independently price future prescription drug costs in MSAs, pharmacy utilization costs have increased significantly. Rising drug costs have caused MSA settlement amounts to double or even triple— making it increasingly difficult to settle claims. To minimize the risk of prolonged settlement negotiations and expedite case closures while mitigating costs— insurance professionals should consider obtaining a Pre-MSA with Drug Regimen Review to gain control of injury-related drug utilization and medical treatment and other high costs associated with MSAs— early in the process.
This course addresses the benefit of identifying and reducing expenses early in the claim process to realize significant savings in time for settlement.
Medicare Conditional Payments: Current Obligations & New Requirements under Senate Bill 2499 (1 hr)
As part of the settlement process, it is necessary to determine if the claimant is entitled to Medicare. Under Section 111 of the Medicare, Medicaid & SCHIP Extension Act (MMSEA), a &lquo;responsible reporting entity&rquo; is required to report claims involving a Medicare beneficiary and provide Medicare with certain information per CMS’ Mandatory Insurer Reporting (MIR) guidelines. The penalty for non-compliance with Section 111 is steep: $1,000 per day, per claim. In addition, if the claimant is a Medicare beneficiary, it is necessary to thoroughly investigate whether Medicare has a claim for &lquo;conditional payments.&rquo; Under the Medicare Secondary Payer Statute (MSP), primary payers and other entities are required to reimburse Medicare for conditional payments. Failure to address the issue of conditional payment reimbursement can subject the primary payer to double damages, result in a loss of benefits for the injured individual, and subject other parties (including attorneys) to a potential action from CMS.
This presentation focuses on the current obligations of primary payers under the MSP Statute and addresses the new &lquo;notice and reporting&rquo; requirements per Section 111 of the MMSEA and CMS’ MIR guidelines related thereto.
Protecting Medicare’s Interests in Cases Not Meeting the CMS Review Thresholds (1 hr)
The Centers for Medicare and Medicaid Services has reinforced that under the Medicare Secondary Payer provisions, Medicare is always secondary to workers’ compensation and other insurance such as no-fault and liability insurance and that the current CMS review thresholds are CMS workload review thresholds only— not substantive dollar or &lquo;safe harbor&rquo; thresholds for complying with Medicare Secondary Payer law. Therefore, Medicare’s interests must always be considered and protected when settling any workers’ compensation case— even if CMS review thresholds are not met. This program outlines several practical approaches to considering and protecting Medicare’s interests in cases not meeting the CMS review thresholds.
Considering Medicare’s Interests in Liability Settlements: It is not just for Workers’ Compensation! (1 hr)
How and when to consider Medicare’s interests in a liability settlement, judgment or award has been a topic of significant discussion among liability carriers and attorneys for some time. The code of Federal Regulations contains special rules for liability insurance settlements. There is significant exposure for carriers, claimants and attorneys— if Medicare’s interests are not adequately considered. This presentation will review the statutory framework, discuss recent guidance provided by CMS staff, and offer practical approaches for considering Medicare’s interests in liability cases.
Medicare Set-Aside Account Administration (1 hr)
Many MSA arrangements are self-administered by injured individuals. However many are not properly screened to determine if Professional Administration is required— or given adequate information and resources to successfully self-administer. Failure to properly administer a MSA account according to CMS guidelines could put a claimant’s future Medicare benefits at risk. This program outlines CMS&rsquo requirements regarding the administration of a MSA account, requirements for both professional and self-administration, common problem areas and other considerations.
Controlling Prescription Drug Costs in MSA Allocations (1 hr)
On December 30, 2005, CMS issued a memorandum addressing the impact of Part D prescription drug coverage on workers’ compensation settlements and has yet to issue a formal policy regarding methods of calculating these costs in MSA allocations. As a result, MSA allocation amounts continue to increase because prescription drugs can be one of the largest cost categories of future medical care. It is critical that every effort be made to appropriately contain the cost of future prescription drugs— while still &lquo;reasonably considering&rquo; Medicare’s interests. This presentation discusses the various methods that may be utilized to calculate the cost of prescription drugs in MSA allocations and methods to control costs.
Medicare Set-Aside Basics: Understanding the three components of a MSA arrangement (1 hr)
When a case requires a Medicare Set-Aside arrangement, the primary focus tends to be on the MSA allocation amount. While the proposed MSA allocation amount is an important factor, equally important is the method of funding the MSA account and the method of administering the MSA account funds post-settlement. This presentation provides participants with an understanding of each of the three components of a MSA arrangement, the options available under each component and the potential pitfalls.
It is imperative that the impact of these changes (and the possible impact of proposed MSP amendments) be properly understood to ensure proper compliance under the MSP. This presentation places these new developments into proper focus to assist primary payers address the changing MSP landscape.
Settling WC Medical Expenses Prior to CMS Approval of a Proposed MSA (1 hr)
CMS issued a policy memorandum on July 11, 2005 addressing the settlement of Workers’ Compensation medical expenses prior to CMS review of a proposed MSA. While the memorandum focused on the provision of proof of full funding to CMS, this presentation addresses several other issues to be considered including repayment of Medicare conditional payments, responsibility for funding of additional amounts required by CMS and the potential for modification of the initial and annual payment amounts for MSA arrangements funded by a structure.
Developing Internal Protocols for Medicare Secondary Compliance (1 hr)
Insurance Carriers and Third-Party Administrators are becoming increasingly aware of the need to develop internal protocols for complying with the MSP provisions and to ensure those protocols are consistently followed. This program outlines the key components that should be considered when developing compliance protocols as well as practical approaches to implementation.
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