Cases & Points Blog

Conditional Payments in Review: 2018

In February of 2018, we saw a new contractor operating Medicare’s Commercial Repayment Center (CRC), Performant Financial Corporation.  As expected, there were growing pains or learning curves experienced with the new operator, such as: inappropriate referrals to U.S. Treasury for collection, letters of authorization inappropriately denied, statement of reimbursement forms not matching decision letters and […]

Confusion, Conjecture and Clarification: The New WCMSA Reference Guide

With the issuance of updated Workers’ Compensation Medicare Set-Aside Reference Guide version 2.9 (Guide), there has some speculation and even confusion as to what is really new and what is an elaboration of old policies and procedures.  Examples listed for off-label drug usage to new bullets added regarding the submission process, all of which begs […]

a medical device over hundred dollar bills

CMS Issues a Revised WCMSA Reference Guide and Section 111 User Guide

The Centers for Medicare and Medicaid Services issued a revised WCMSA Reference Guide (Reference Guide), Version 2.9, which can be found here: WCMSA Reference Guide.  In addition to changes to development and alert templates; references to removal of certain memorandum from cms.gov; and reference to the updated CDC Life Table, the Reference Guide also includes updates […]

doctor gathers in a circle reviewing a tablet device

CMS and Medicaid to Convert to CDC 2015 Life Table

The Centers for Medicare and Medicaid Services has announced that it will convert to the CDC’s “Table 1: Life Table for the total population: United States, 2015“ for Workers’ Compensation Medicare Set-Aside life expectancy calculations.  The change to the updated life table will become effective as of January 5, 2019.  There is a slight increase […]

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The OMB Issues Intent of Notice of Proposed Rule Making for Section 111 Penalties

In an abstract entitled “Civil Money Penalties and Medicare Secondary Payer Reporting Requirements,” the Office of Management and Budget has issued another intent of Notice of Proposed Rulemaking this time involving Section 111 Reporting penalties.  Specifically, the abstract of the Notice provides as follows: Section 516 of the Medicare Access and CHIP Reauthorization Act of […]

a medical device over hundred dollar bills

Office of Management and Budget Issues Proposed Rulemaking Regarding MSP Compliance Options

Under the title “ Miscellaneous Medicare Secondary Payer Clarifications and Updates,” the Office of Management and Budget issued proposed rulemaking to address Medicare Secondary Payer obligations in the context of automobile and liability insurance, no-fault insurance and workers’ compensation recovery.  The abstract of the proposed rule states as follows: “This proposed rule would ensure that […]

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Success in the CMS Re-Review Process

Pursuant to Section 16.0 of the Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide, Version 2.8, October 1, 2018, COBR-Q4-2018-v2.8, CMS will conduct a Re-Review of a prior WCMSA determination in certain circumstances.  Specifically, CMS will complete this process in cases involving a mistake in the allocation; mathematical error; or when there is missing documentation […]

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Settlement reporting threshold of $750 remains for 2019 and Enhancements to the Medicare Secondary Payer Recovery Portal (MSPRP) Coming 1/7/2019.

On 11/15/2018, Medicare issued its annual recovery threshold calculation. This threshold determines the amount of settlement, judgement or award that must be reported to Medicare under the Section 111 reporting rules. For 2019, any settlement, judgement, award at or above $750.00 should be reported to Medicare through Section 111 reporting.  Medicare’s announcement can be found […]

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Failure to Properly Use the Conditional Payment Administrative Appeal Process

In Mouradian v. United States Government, the United States District Court for the District of Massachusetts found that a Medicare beneficiary did not exhaust the conditional payment administrative appeal process. Because the administrative appeal process was not exhausted, the District Court could not make a decision regarding whether the Medicare Secondary Payer Act (MSP Act) […]