CMS published the first memo to address Liability Medicare Set Asides on September 30. The memo states that “Where the beneficiary’s treating physician certifies in writing that treatment for the alleged injury related to the liability insurance (including self-insurance) “settlement” has been completed as of the date of the “settlement”, and that future medical items and/or services for that injury will not be required, Medicare considers its interest, with respect to future medicals for that particular “settlement”, satisfied.”

This CMS memo is the first to specifically address future medical payments in Liability settlements. It appears clear from this memo that settling Liability cases without taking future medicals into account and without written certification from the treating physician that no continued care is needed, may be a thing of the past.

For more information on protecting Medicare’s interest join us for our upcoming seminar or call us for more information on our Medicare Set Aside and Medical Cost Projection Services.

Celebrating Independence Day

State Rulings Challenging CMS, Interpreting the MSP, CMS Temporarily Suspending Issuance of Conditional Lien Letters, CMS Changing Contractors, maybe not fireworks, but it has made for a lively Spring in the Medicare Secondary Payer arena and pushed time-lines for settlement of many claims, negotiation of liens and general response.

Florida led the pack last year in challenging CMS and the MSP. This spring, on May 5, 2011, U.S. District Court, Arizona, Haro v. Sebelius challenged CMS’ interpretation of the MSP act. The court found that, “Defendant’s demand for payment of her MSP reimbursement claims, under threat of collection actions before there has been a resolution of an appeal regarding the amount of the Defendant’s MSP claim or a waiver request, exceeds her authority under the Medicare statute, and Defendant is enjoined from demanding payment of a MSP reimbursement claim with threats of commencing collection actions before there is a resolution of an appeal or waiver request. “ And, “that the Defendant’s demand that attorneys withhold liability proceeds from clients pending payment of amounts claimed by the Defendant as MSP reimbursement exceeds her authority under the Medicare statute, and Defendant is enjoined from demanding that attorneys withhold liability proceeds from their clients pending payment of disputed MSP reimbursement claims “ This ruling is thought by many to be largely responsible for the temporary suspension of the issuance of Conditional Lien Letters and for the recently released revised letter templates. http://scholar.google.com/scholar_case?case=4684802788206507286&hl=en&as

On May 6, 2011, Western District of New York, established a “Medicare Secondary Payor Protocol,” for liability claims. The big surprise here was the establishment of a $350,000 threshold within the protocol. NY-MSP_Protocol-4

Next, we take note of   the Superior Court of New Jersey, Hinsinger v. Showboat Atlantic City, Approved Decision for Publication May 19, 2011. This put a new light on “procurement cost”, allowing attorney’s fees to be considered for deduction from the Medicare Set Aside Funds, stating that the MSP directive prohibiting such, applies only to attorney fees “specifically associated with establishing” the trust.  NJ Medicare Ruling

Then, on 6/15/11, in the case of Wilson v. State Farm Mutual Automobile Insurance Company, US District Court for the Western District of KY, ruled that an insurance carrier did not act in “bad faith” by delaying payment of a settlement pending receipt of determination of Medicare’s reimbursable conditional payment amount.

These precedence-setting cases have indeed raised some eyebrows and begun reshaping the MSP world. As we celebrate our Independence this July 4^th, it only seems prudent to recognize these cases and smile. Though we often quickly point out issues in the American system, I can’t help but smile, realizing, even now, we are watching the system at work, creating law, in a land of the people, for the people and by the people. Wishing you and yours a Happy and Safe July 4^th Holiday!

‘Twas two weeks before Christmas and to the post office we went,

measuring and weighing our packages to be sent.

They checked them once and checked them twice and stated, sixty-one cents should suffice.

We stuffed, we labeled, we glued and boxed,

then we carried our packages to the US Post Box.

They gladly received and placed in a bin and we walked out with a very content grin.

A few days later, what to our wondering eyes should appear but returned packages stamped you owe we won’t deliver you hear?

The postmaster explains, a mistake has been made and now you may have an avalanche of return  mail on Christmas Day.

And so, if your package from us you did not receive and you had no star cookies for Santa under your tree,

Your star cookie cutter may very well be in Montana, South Dakota, Indiana, or back under our tree.

But of this we are certain despite the mistake, the Holiday came whether cookies were baked.

So, if a customized approach to your cases you seek send us an email or give us a call. Please don’t send us a letter we may not get at all.

Wishing you health, happiness and blessings as we look forward to serving you in the New Year.

Alisa

Well, as my grandmother use to say, it’s because “the devil is in the details.”  And, it is the details or the accuracy of the details that are often lacking.

I am convinced that defense and plaintiff alike believe that persons who experience catastrophic injury should be afforded the opportunity to rehabilitate to their fullest potential and maintain quality of life.

The goal of a life care plan should be to capture current and future needs of the injured party and to accurately identify the cost of providing for these needs. This requires looking at the details, local service providers, multiple sources, specific wheelchairs, family dynamics, state guidelines for levels of care specific to the individual’s ability and status, local transportation companies and vehicle inventories and many more.

The plan should actually be a tool, not just for litigation purposes but also for the individual and the family. It should not overstate or understate the needs.

We are often utilized to review life care plans and far too often we find cases that have been prepared with less than desired attention to detail and this often results in inclusion of inappropriate items or exclusion of needed items within the plan.

For example, sometimes providers of care that are included and quoted in the plan do not service the injured party’s geographic region.  Not every “home-health care” chain covers the entire Boston area and all of the outlaying suburbs.  Important? Yes, it can make up to a $5.00 per hour difference. If you multiply that out over a lifetime, well, I am sure you realize the impact.

We have reviewed cases where discontinued drugs were included in the plan and other cases where newly prescribed drugs were excluded. Important? Absolutely! In one case it made a $313,600 difference in the prescription drug projection.

Another example is when two treatment modalities, which accomplish the same goal, are dually included within a plan.  The plan calls for building a home gym for therapy and having the therapist come to the house for appointments and it also calls for therapy visits to an outside office.  Some plans reviewed have included more forms of therapy and physician visits than a person could even possibly fit into a day.  Separately, each component seems to make sense but when combined into the plan there are many overlapping components and some may need to be reduced and others completely eliminated.

Just as things may need to be eliminated, sadly, sometimes the most basic items such as hand controls for a vehicle or an appropriate wheelchair are left out.  When this happens no one achieves the desired result.

You may be wondering, “Well, how often can things like that happen? “Often enough, that to date, our ROI for life care plan reviews has ranged from 10:1 to 300:1. I guess, my grandmother was right. It is very important to major in the details rather than have that nasty little devil trip you up!

CMS has issued much needed clarification regarding the rated age language changes that were published in the May 14, 2010 memo. The new language is much more practical as the requirement is now that any rated ages obtained on or after the date of injury must be included. Check out the memo for yourself CMS June 2010 Memo.

At Concierge Medical and Risk Consultants we are glad to assist you with any Medicare Compliance needs.  Please let us know how we can help you!

CMS just released a new memo regarding the off label use of prescription drugs and their place in a Medicare Set Aside. This memo also addresses the use of rated ages and the language that must be included in the MSA for a rated age to be considered. It appears that CMS wants certification that every rated age obtained in the claimant’s lifetime be submitted. I find this to be problematic as rated ages have expiration’s, for the very reason that a rated age obtained when one is 20 years old and in the best shape of their life may look very different from a rated age obtained at 65 after 30 years of chain smoking, over-eating and a newly developed health history which includes diabetes and heart disease.  I have attached the memo for your reference and I do think that some good will come out of the first portion of the memo which addresses the off label use of prescription drugs.

13 May-14-2010 Memo

With the state of Maryland adding Medicare protection to their Workers’ Comp law, imminent changes in CMS (Center for Medicare Services) reporting guidelines, and the recently enacted Health-care reform, Corporate America has a great opportunity to reassess their risk control strategies. This is one area each organization can do something about. It’s an area of direct control.

By analyzing loss trends and developing strategies to both prevent and mitigate losses the bottom line of an organization can be enhanced. An organization’s risk control efforts should focus on increasing productivity, providing a significant return on investment while having a positive impact on corporate culture.

So, we encourage you, take this opportunity, seize the moment, and offset the cost of impending legislation by employing a strategic, winning Risk Control Plan. Need assistance? Contact us.

Reminder concerning Liability, No Fault, and Workers Compensation RREs.  January 1, 2010 through March 31, 2010 is the testing period, if not already submitting.  All Liability, No Fault and Workers Compensation RREs will be submitting Section 111 files by 4/1/2010.

For more information check the 9-5-08, 3-20-09, and 5-11-09 Alerts from the Center for Medicare Services.

All Responsible Reporting Entities (RREs) must be registered by 9/30/09 via the COBSW website.

Not yet registered?  Avoid possible penalty, follow the link below to set up your account as an RRE by 9/30/09.

COBSW RRE Registration

Not sure if you need to register – Contact us and we would be glad to assist you in determining if you must register.