YOUR MEDICARE PROBLEM SOLVERS A N D
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- Abigayle Underwood
- 5 years ago
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1 A N D To: Plaintiff s Trial Attorneys RE: Medicare Conditional Payment (CP) Lien Resolution Letter of Engagement Dear Mr./Ms. Attorney: So that we can best serve you, your firm and your client, we kindly ask that you give our office a call ( ) prior to the submission of the below intake forms so that we may address any general case questions you may have. This free, brief, upfront call will also afford us the opportunity to prepare a plan of action that is specific to your case so that once we receive the intake forms and relevant documents, we can get to work immediately. This short call and discussion is the best way we know of to prove our immediate value to you, without you risking a penny of your (or your client s) money. After our initial conversation, please complete the following steps and return the enclosed/attached documents to our office via at liens@plaintiffsmsa.com or fax them to Step 1: New Case Intake Form (page 2) - Please complete as precisely as possible. It helps us do our best work for your client, and eliminates a call to you or your staff; Step 2: CMS Proof of Representation Form: (page 3) - To be signed by your client ( Beneficiary ) and by you as the retained attorney (where it says: Representative ); Step 3: Precision Resolution Proof of Representation Language (page 4) - To be copied or printed onto your own firm s letterhead and signed by you as the Beneficiary s Attorney. Once the executed form is forwarded to Precision, our attorney representative will execute same; Step 4: Review our Fee Schedule and Billing Policies (page 5) - Sending us a New Case Intake Form signifies your acceptance of such fees; and Step 5: Case Submission Fee - Payment of the Case Submission Fee in the amount of $750 is due, in entirety, prior to the commencement of any service rendered. Prepare a check made payable to Precision Resolution, LLC and mail to the Plaintiff's MSA & Lien Solution address shown below. ADDITIONALLY, IF YOU HAVE RECEIVED ANY CORRESPONDENCE FROM CMS OR THE MSPRC RELATED TO THE SUBMITTED MATTER(S), PLEASE FORWARD ALL CORRESPONDENCES RECEIVED TO OUR ATTENTION WITH THE ABOVE-REFERENCED DOCUMENTS. Upon our receipt of the above-required documents and retainer check, an will be sent to your attention confirming receipt of the documents and check. Any invoices for the reduction of a lien amount negotiated will be forwarded to your attention at the time of resolution. Thank you for your confidence in Plaintiff's MSA and Lien Solution and Precision Resolution. We look forward to providing you with a PRECISION RESOLUTION. Best regards, j Jack L. Meligan, RSP, BCFE, MSCC, CMSP The Plaintiff's MSA and Lien Solution, LLC 1800 Blankenship Rd., Ste. 160 West Linn, OR (T) (F) YOUR MEDICARE PROBLEM SOLVERS When dealing with compliance and lien resolution matters, always demand Precision. ADDRESS The Plaintiff's MSA and Lien Solution 1800 Blankenship Rd., Ste. 160 West Linn, OR TELEPHONE P: F: WEB/ liens@plaintiffsmsa.com V
2 New Case Intake Form Referring Settlement Planner: Date of Request / / The Plaintiff's MSA /SPI Home Ofc So that Precision may begin processing your file immediately, please submit this completed form, along with any/all additional authorization forms to liens@plaintiffsmsa.com Nature of Injury Attorney Information Name DOI / / DOD (if applicable) / / Pho ne _ Fax Specific Nature of Accepted Injuries Firm Address City State Zip Attorney Paralegal/Associate Contact Paralegal/Associate Still Treating Last Treatment Date / / Known Pre-Existing Conditions Claimant Information Nature of Claim Name Female Male Motor Vehicle Accident SSN DOB / / Address _ City State Zip NO-FAULT Gender Phone * *If yes, what state(s)? APIP Carrier LIABILITY Social Security Disability Insurance Claimant Receiving (Past or Present) Case Reported to Agency Exposure Product Liability Other Liability Carrier WORKERS COMP Comments Services Requested Check all that Apply Medical Malpractice Nursing Home Negligence Slip & Fall Settlement Amount $ Settlement/Anticipated Settlement Date / / OTHER BENEFITS RECEIVED Fault Carrier Settlement Information Fault Policy? Might APIP be Obligated to Pay Medicals? APIP Has claimant lived in another state since date of injury? Has this case settled? (check all that apply) Supplemental Security Income WC Carrier Full & Proper Name Other Relevant Claim Information Please submit a copy of any/all correspondences with agency and claimant's insurance cards, along with this and all other authorization forms to liens@plaintiffsmsa.com or fax to Medicare Conditional Payment (Parts A/B ) HIC # Entitlement Date / / Medicare Advantage (Parts C/D) Insurance Company Name Group/ID # Medicaid Medicaid # State(s) Plan Docs Requested? Self-Funded ERISA or Other Private Healthcare * TRICARE Insurance Company Name Group/ID # If Employer-based Health Plan, specify employer name *Please provide Plan Document or Summary Plan Description if available. Treatment Facilities Sponsor SSN Veteran s Administration Treatment Facilities Sponsor SSN Additional Comments Plaintiff's MSA and Lien Solution, 1800 Blankenship Rd., Ste. 160, West Linn, OR (t) (F) (E) liens@plaintiffsmsa.com
3 PROOF OF REPRESENTATION The undersigned Medicare beneficiary informs the Centers for Medicare & Medicaid Services (CMS) that they have given the specified legal representative the authority to represent them and act on their behalf with respect to any claims for liability insurance, no-fault insurance, or workers compensation, including releasing identifiable healthh informationn or resolving any potential recovery claim that Medicaree may have if there is a settlement, judgment, award, or other payment. The undersigned representative agrees that they represent the stated Medicare beneficiary. Type of Representative: ( ) Individual other than an Attorney: ( X ) Attorney ( ) Guardian* ( ) Conservator* ( ) Power of Attorney* Authorizedd Representative: (Attorney/ Law Firm Name) (Law Firm Address) (Law Firm City, State, Zip) (Phone Number) * If the beneficiary is incapacitated, his/her guardian, conservator, power of attorney etc. will need to submit documentation in addition to this proof of representation. Medicare Beneficiary Information: Beneficiary s Name (please print exactly as shown on your Medicare card): Beneficiary s Health Insurance Claim Number (number on Medicare card): Date of Illness/Injury for which the beneficiary has filed a liability insurance, no-fault insurance or workers compensation claim: Beneficiary s Signature: Date signed: Representative s Signature: (Attorney) Date signed: GFRG-2010
4 Medicare Secondary Payer Recovery Contractor MSPRC-NGHP Post Office Box Oklahoma City, OK RE: PRECISION RESOLUTION, LLC PROOF OF REPRESENTATION Beneficiary: HIC#: Date of Incident: Dear Sir or Madam: Please be advised that, the attorney for the above referenced Medicare beneficiary, has appointed as representative regarding the resolution of any Medicare conditional payment issues pertaining to this file. Please provide with any information regarding this claim to the following address: 4134 Seneca Street Buffalo, NY Signature of Beneficiary s Attorney: Representative s Signature: Paul R. Loudenslager, Esq.
5 Medicare Conditional Payments and Medicare Lien Resolution Fee Schedule Service Fee Fees Due to PR Opening, Tracking, Challenge and Closing of Medicare File Successful Challenge Resulting in a Reduction of Lien Amount $ Upon Submission of Intake and Authorization Forms to Precision plus, in the event of a successful challenge: 15% of Reduction with a $5, cap on fees for all services rendered* Payment for the reduction of a lien amount resulting from a challenge filed by Precision shall be due at the time of Medicare s (or other governing body s) decision. *This fee applies to reductions of the lien amount as a result from a formal challenge of a lien. Medicare s standard reductions for attorney s fees and procurement costs, etc. is not a billable service rendered by Precision. Appeals made to an Administrative Law Judge would be billed at an additional cost of $ an hour, plus 25% of the reduction of the lien amount. Please make all checks payable to and mail all checks for services rendered, with the case name in the memo line, to: c/o Plaintiff's MSA & Lien Solution, LLC 1800 Blankenship Rd., Ste. 160 West Linn, OR Upon receipt of the payment, Precision will forward a paid invoice to your attention and begin work on the file. Please direct any billing specific questions to billing@precisionlienresolution.com. Tax ID: Always demand Precision Seneca Street, Buffalo, NY (T) LIEN (F) (E) submit@precisionlienresolution.com
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