Cases & Points Blog

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 […]

CMS Releases Documents from Section 111 NGHP Webinar

As a follow-up to the Section 111 NGHP webinar held on August 13, 2020, CMS has now released the slides from the webinar as well as the answers to various questions posed after the presentation.  NuQuest posted a prior blog on the highlights from this presentation which can be found here. Should you have any […]

New CMS Alert on Section 111 Webinar Presentation

CMS has released the August 13, 2020 Section 111 Non-Group Health Plan Reporting webinar presentation.  The presentation can be accessed on the download section of the Mandatory Insurer Reporting for Non-Group Health Plans What’s New page or through the following link: _https://www.cms.gov/files/document/august-13-2020-section-111-non-group-health-plan-reporting-webinar-presentation.pdf.  Questions and answers from the webinar will also be released by CMS in […]

Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Applicable Plan Recovery Webinar: Appeals

CMS will be hosting a CRC NGHP Applicable Plan webinar to review the procedures and best practices for redeterminations. The format will be opening remarks by CMS followed by a presentation from the CRC. This webinar will primarily focus upon how to effectively submit a redetermination request (sometimes called a first level appeal). During the […]