Cases & Points Blog

The PAID Act Becomes Law

The Provide Accurate Information Directly (PAID) Act, has been passed by the U.S. Congress and was signed by President Trump on December 11, 2020.   The purpose of the PAID Act is to address the lack of a centralized process to identify Medicare Advantage Plan and Medicare Part D Prescription Drug Plan beneficiaries.  Currently, the Section […]

Is your conditional payment negotiation game up to speed?

There are two entities initiating the recovery of conditional payments for Medicare Part A and B: Benefits Coordination Recovery Center (BCRC) and Commercial Repayment Center (CRC).  CRC collects based upon Ongoing Responsibility for Medical (ORM) reporting entered through the claims system from a carrier/self-insured (or their TPA). In denied cases where ORM is not reported […]

NuQuest Appoints Barbara Fairchild to Role of Chief Executive Officer

NuQuest, the leading provider of Medicare Secondary Payer (MSP) compliance solutions, including Medicare Set-Aside Allocation (MSA), Medical Cost Projection, and Professional Administration services, is pleased to announce the confirmation of Barbara Fairchild as Chief Executive Officer. Under Ms. Fairchild’s leadership, we look forward to a vibrant and flourishing future for our organization and for the […]

CMS News to Note

November was a busy month for CMS with the issuance of a new NGHP User Guide, Version 6.1 and multiple alerts.  Below is a brief summary of these updates.  2021 Recovery Threshold Alert On November 25, 2020, CMS issued a new alert on the 2021 Recovery Thresholds beginning on January 1, 2021.  The alert notes […]

Section 111: What is Medicare missing?

Workers’ compensation and liability insurance carriers have the obligation to report two essential events if a claim involves a Medicare Beneficiary: Ongoing Responsibility for Medical (ORM) Settlement, judgment, award, or other payment Medicare refers to a settlement, judgment award, or other payment as “Total Payment Obligation to Claimant (TPOC).” These two events require the carrier/self-insured […]

CMS has issued a Commercial Repayment Center Non-Group Health Plan Applicable Plan Appeal Guide

CMS has issued a Commercial Repayment Center Non-Group Health Plan Applicable Plan Appeal Guide (Appeal Guide) in the Download section on the Insurer NGHP Recovery page on CMS.gov.  A copy of the Appeal Guide can be found here.  The Appeal Guide outlines the steps in the  appeals process; appeal requirements; necessary authorizations; what is and […]

CMS Issues Section 111 NGHP User Guide Version 6.0

The new Section 111 NGHP User Guide 6.0 (Guide) was issued by CMS on October 5, 2020 and contains several updates as noted below. Chapter III, Section 4.6 of the Guide, CMS has specified what items should be included when calculating the Total Payment Obligation to Claimant (TPOC).  CMS notes that the “TPOC amount includes, […]

New WCMSA Reference Guide 3.2 Issued by CMS

On October 5, 2020, CMS issued a new WCMSA Reference Guide (Guide) version 3.2.  Changes to the Guide include defining what major medical centers the Workers’ Compensation Review Contractors (WCRC) utilize for pricing surgical interventions in WCMSAs.  A copy of the new Guide can be found here. Specifically, CMS added a new Appendix 7 to […]

Downstream Actors May Have a Right to Reimbursement

Downstream Actors May Have a Right to Reimbursement: MSP Recovery Claims v. Ace Am. Ins. Co, 2020 U.S. Dist. Lexis 28610 In Ace, the U.S. Court of Appeals for Eleventh Circuit reversed a District Court’s decision and determined that a “downstream actor” from a Medicare Advantage Organization (MAO) had the right to seek reimbursement under […]

Medicare Advantage Organization Seeks More than Double Damages

Medicare Advantage Organization Seeks More than Double Damages: Aetna Life Ins. Co. v. Guerrera, 2020 U.S. Dist. Lexis 139949 In Aetna Life Ins. Co. v. Guerrera, the U.S. District Court for Connecticut determined that a liability insurance carrier was responsible for conditional payments associated with a settlement with a Medicare beneficiary. In the circumstances of […]