Work-Accident -Compensation Accident Claim Work: Medicaid

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Sabtu, 01 Oktober 2011

New CMS Policy Announced: Asbestos Exposure, Ingestion, and Implantation Issues and December 5, 1980

The Centers for Medicare & Medicaid Services has consistently applied the Medicare Secondary Payer (MSP) provision for liability insurance (including self-insurance) effective 12/5/1980. As a matter of policy, Medicare does not assert a MSP liability insurance based recovery claim against settlements, judgments, awards, or other payments, where the date of incident (DOI) occurred before 12/5/1980.

When a case involves continued exposure to an environmental hazard, or continued ingestion of a particular substance, Medicare focuses on the date of last exposure or ingestion for purposes of determining whether the exposure or ingestion occurred on or after 12/5/1980. Similarly, in cases involving ruptured implants that allegedly led to a toxic exposure, the exposure guidance or date of last exposure is used. For non-ruptured implanted medical devices, Medicare focuses on the date the implant was removed. (Note: The term “exposure” refers to the claimant’s actual physical exposure to the alleged environmental toxin, not the defendant’s legal exposure to liability.)

In the following situations, Medicare will assert a recovery claim against settlements, judgments, awards, or other payments, and the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) Section 111 MSP mandatory reporting rules must be followed:

• Exposure, ingestion, or the alleged effects of an implant on or after 12/5/1980 is claimed, released, or effectively released.

• A specified length of exposure or ingestion is required in order for the claimant to obtain the settlement, judgment, award, or other payment, and the claimant’s date of first exposure plus the specified length of time in the settlement, judgment, award or other payment equals a date on or after 12/5/1980. This also applies to implanted medical devices.

• A requirement of the settlement, judgment, award, or other payment is that the claimant was exposed to, or ingested, a substance on or after 12/5/1980. This rule also applies if the settlement, judgment, award, or other payment depends on an implant that was never removed or was removed on or after 12/5/1980.

When ALL of the following criteria are met, Medicare will not assert a recovery claim against a liability insurance (including self-insurance) settlement, judgment, award, or other payment; and MMSEA Section 111 MSP reporting is not required. (Note: Where multiple defendants are involved, the claimant must meet all of these criteria for each individual defendant in order for a settlement, judgment, award, or other payment from that defendant to be exempt from a potential
MSP recovery claim and MMSEA Section 111 reporting):

•All exposure or ingestion ended, or the implant was removed before 12/5/1980; and

•Exposure, ingestion, or an implant on or after 12/5/1980 has not been claimed and/or specifically released; and,

•There is either no release for the exposure, ingestion, or an implant on or after 12/5/1980; or where there is such a release, it is a broad general release (rather than a specific release), which effectively releases exposure or ingestion on or after 12/5/1980. The rule also applies if the broad general release involves an implant.

For Specific Examples Click Here To Read the CMS Memo

REPORTING REMINDER:

Information related to the MMSEA Section 111 MSP reporting requirements can be found at
www.cms.hhs.gov/MandatoryInsRep. When reporting a potential settlement, judgment, award, or other payment related to exposure, ingestion, or implantation, the date of first exposure/date of first ingestion/date of implantation is the date that MUST be reported as the DOI. This is true for purposes of individual self-identification of a pending claim to the Centers for Medicare & Medicaid Services’ Coordination of Benefits Contractor, as well as for MMSEA Section 111 reporting.
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Rabu, 22 Juni 2011

Congress Told CMS Must Continue to Stop Work Comp Cost Shifting

At a House Oversight hearing today it was revealed that over the last decade the Centers for Medicare and Medicaid Service (CMS) has obtained over $50 Billion in reimbursement under the Medicare Secondary Payer Act (MSP). CMS has worked diligently to stop cost shifting from workers' compensation insurance carriers to the US taxpayer.

Deborah Taylor, Chief Financial Officer and Director, Office of Financial Management Centers for Medicare and Medicaid Services, stated, "Any restrictions on existing MSP rights or recovery processes would adversely affect savings that would otherwise accrue to the Medicare Trust Funds through MSP recovery activities, as well as the $1 billion per year in cost-avoided savings that CMS is able to track. Proposals that would impose mandatory process changes may affect Medicare’s status as a secondary payer or its priority right of recovery, as well as CMS’ ability to prioritize its own workload. These changes may also have the unintended effect of undercutting the underlying intent of the statute, increasing costs, and reducing existing savings. "

Ms. Taylor concluded by stating that, "...CMS is committed to a transparent MSP process that ensures that beneficiaries receive the care they need, while reducing Medicare payments for claims that are the legal responsibility of a group health plan, NGHP, or other responsible party. We understand that the MSP process can present challenges to all involved in coordination of benefits between Medicare and other payers. We are committed to maintaining a strong line of communication with beneficiaries, insurance and workers’ compensation plans, and other stakeholders on MSP policy in general, as well as the new Section 111 reporting requirements. Additionally, we will look to expand and strengthen our training and education opportunities where possible. CMS looks forward to working with our partners and beneficiaries in the future to preserve the integrity of the Medicare program and secure the Medicare Trust Funds for future generations. We look forward to working with Congress as well on these important goals."

Related Resources

Medicare Secondary Payer: Process for Situations Involving Non-Group Health Plans, US GAO Study James C. Cosgrove, Director, Health Care - 6.22.11

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Jumat, 18 Maret 2011

Industry Coalition Wants to Cut CMS Conditional Payments

A group of about 50 employers, insurance carriers and vendors have formed a coalition to endorse legislation (H.R.1063) introduced this week that would ease reporting requirements and reimbursement procedures of the Centers for Medicare and Medicaid (CMS). The organization, the Medicare Advocacy Recovery Group [MARC], contends that the proposed legislation will:

"Empowering Medicare to provide settling parties with the amount of their MSP repayment obligation during the settlement process, will allow taxpayers to settle quicker, and repay the Medicare Trust Fund faster.
"MSP Reform will provide a more affordable and less intrusive MSP system that protects beneficiaries and the Medicare Trust Fund, but does not waste limited judicial and other resources or needlessly confuse parties trying to settle a claim resulting from an injury to a beneficiary.
"MSP Reform will also eliminate the required use of Social Security Numbers (SSNs) and Health Insurance Claim Numbers (HICNs) in the reporting process, create a basic right of appeal for all parties to resolve a CMS MSP determination, clarify the statute of limitations, and require the CMS Actuary to determine a threshold below which the recoveries are so small it makes no sense to apply the complex MSP laws.

Theoretically it sounds like the change would create a more efficient system to establish: time limits for claim reimbursement; a statute of limitations for liability (3 years); an avenue for redress directly to the judicial system; and a threshold amount for reimbursement. However, the proposal would actually defeat the basic philosophy of the workers' compensation act.

The convoluted logic of the employer/insurance group just makes no sense. It is like saying that I didn't bother buying enough postage on a timely basis so I will just mail my letter at half-price. The universal legislative intent of workers' compensation act mandates that the employer is responsible for medical care of its injured workers. The insurance industry has tried other gimmicks before to continue its long history of cost shifting, and those have rightly failed as Congress wouldn't buy into them.

While employers and insurance carriers delay and deny compensation benefits, shifting the cost to the taxpayers through depletion of the Medicare system, is both offensive and repugnant. If the coalition wants to ride the carousel of "it's not how long, but how much," in doling out benefits, then they should not blame CMS for delays and penalties, caused by the coalition's own failure to report on a timely basis in the first place.

Kamis, 17 Februari 2011

Medicare Secondary Payment Interest Calculation Tool Updated

The Medicare Secondary Payer Recovery Contractor (MSPRC) has published an updated version of its Interest Calculation Tool.

Interest Periods tab

Demands before October 2004 tab

How Interest is Calculated tab

Download

Kamis, 02 Desember 2010

CMS Issues Series of Mandatory Reporting Alerts

Centers for Medicare and Medicaid Services (Me...

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The Centers for Medicare and Medicaid Services (CMS) has recently issued a series of Alerts for Implementation of Medicare Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (See 42 U.S.C. 1395y(b)(7) & (8)).

One of Alerts defines the Date of Incidence (DOI) for a cumulative injury which is the earlier of:

• The date that treatment for any manifestation of the cumulative injury began when such treatment preceded formal diagnosis; or
• The first date that formal diagnosis was made by any medical practitioner.

MMSEA 111 - Alert - November 18, 2010 - ALERT: Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers' Compensation - Special Default ICD-9 Code for Responsible Reporting Entities (RREs) [PDF 69.45KB]

MMSEA 111 - Alert - November 18, 2010 - ALERT: TIN Reference File Address Validation Information for Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers' Compensation Responsible Reporting Entities (RREs) [PDF 58.76KB]

MMSEA 111 - Alert- November 9, 2010 - I. Revised Implementation Timeline for TPOC Liability Insurance (Including Self-Insurance) Settlements, Judgments, Awards or Other Payments and II. Extension of Current Dollar Thresholds for Liability Insurance (Including Self-Insurance) and Workers' Compensation [PDF 46.95KB]

MMSEA 111 - Revised Alert - November 5, 2010 - Direct Data Entry (DDE) Registration Information for Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers' Compensation [PDF 49.17KB]

MMSEA 111 – Revised Alert - November 5, 2010 - New Direct Data Entry (DDE) Option for Liability Insurance (Including Self-Insurance), No-Fault Insurance and Workers' Compensation [PDF 65.37KB]

MMSEA111 - Alert - October 14, 2010 - Alert For Liability (Including Self-Insurance), No-Fault Insurance and Workers' Compensation - Reporting Timeframe [PDF 44.34KB]

MMSEA111 - Alert - October 14, 2010 - Alert For Liability (Including Self-Insurance), No-Fault Insurance and Workers' Compensation - DOI For Cumulative Injury [PDF 40.89KB]

New information concerning ICD Provider & Diagnostic Codes has also been posted to the CMS website:
Version 28 Full and Abbreviated Code Titles - Effective October 1, 2010 [ZIP 922KB]

Conversion information to the proposed (NEW) ICD-10 Codes is also posted.

Selasa, 16 November 2010

CMS Extends Interim Dollar Reporting Threshold Date

II. Extension of Current Dollar Thresholds for Liability Insurance
(Including Self-Insurance) and Workers’ Compensation

The interim dollar reporting thresholds set forth in Section 11.4 of version 3.1 of the MMSEA 111 Liability Insurance (Including Self-Insurance), No-Fault, and Workers’ Compensation User Guide have all been extended by one calendar year.

Under Section 11.4, “Workers’ Compensation ORM”, the date 12/31/2011 is changed to 12/31/2012.
Under Section 11.4, “Liability Insurance and Workers’ Compensation TPOC Amounts”, the last four bullets are revised to read:
• Claim reports where the last (most recent) TPOC Date is prior to January 1, 2013 with TPOC Amounts totaling $0.00 - $5,000.00, are exempt from reporting. Initial claim reports (add records) with no ORM (ORM Indicator = ‘N’) where the most recent TPOC Date is prior to January 1, 2013 with a total TPOC amount less than or equal to $5000.00 will be rejected.
• Claim reports where the last (most recent) TPOC Date is January 1, 2013 through December 31, 2013 with TPOC Amounts totaling $0.00 - $2000.00, are exempt from reporting. Initial claim reports (add records) with no ORM (ORM Indicator = ‘N’) where the most recent TPOC Date is prior to January 1, 2014 with a total TPOC amount less than or equal to $2000.00 will be rejected.
• Claim reports where the last (most recent) TPOC Date is January 1, 2014 through December 31, 2014, with TPOC Amounts totaling $0.00 - $600.00 are exempt from reporting. Initial claim reports (add records) with no ORM (ORM Indicator = ‘N’) where the most recent TPOC Date is prior to January 1, 2015 with a total TPOC amount less than or equal to $600.00 will be rejected.
• No threshold applies to claims where the last (most recent) TPOC Date is January 1, 2015 and subsequent.

November 09, 2010
Medicare Secondary Payer Mandatory Reporting Provisions in
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007
(See 42 U.S.C. 1395y(b)(7)&(b)(8))