Medicare Secondary Payer Compliance. What Risk Managers Should Know. Roy A. Franco, Esq.

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2 Medicare Secondary Payer Compliance What Risk Managers Should Know Roy A. Franco, Esq.

3 Everything you should have known, better now know, and hop that our third party administrator and attorney does know about the Medicare Secondary Payer Act and Section 111 as it relates to Workers Compensation and General Liability Claims Handling.

4 My Background Risk Manager Lawyer Legislative Advocate Arbitrator / Mediator MARC Fundraiser Business Owner In-depth Knowledge Creative Solutions Real Results!

5 Pay it Back Medicare Secondary Payer ABCs Pay it Forward Report it

6 Medicare Secondary Payer Government Players

7 Pay it Back MSP Conditional Payments Accident occurs. Hospital and Health Care Providers bill Medicare. Attorneys, Self Insureds and Carriers become aware of Medicare involvement. Voluntary report to Coordination of Benefits Contractor (COBC). COBC Populates Common Working File (CWF) Transmits to MSPRC in 48 hours. Recovery Management Accounting System identifies medical items and services. 65 days 35 days 35 days Rights and Responsibilities Letter sent by MSPRC within 7 10 days from COBC transmittal. MSPRC issues Conditional Payment Letter consider mymedicare.gov MSPRC negotiates with authorized representative dispute of unrelated claims. Updated Conditional Payment Letter is sent (alternatively see Settlement occurs. Parties send MSPRC Cover Sheet, Final Settlement Detail and Settlement Documents. AGREES 60 days Final demand. RESOLVED Send MSPRC the reimbursement check. MSPRC Conditional Payment Case complete. DISAGREES Relatedness, waiver or compromise. Interest accrues, if full refund not received in 60 days. If full refund not received, MSPRC sends Intent to Refer Letter to Treasury. If full refund not received after 120 days, case is referred to Treasury. In-depth Knowledge Creative Solutions Real Results! DOT pursues recovery against, primary plan, attorneys and/or Beneficiary

8 Pay it Forward Protecting Medicare s Interest Workers Compensation CMS Recommended Policy See /04_wcsetaside.asp Regulations 42 CFR Significant history & vendor involvement No rules for Class III Claims Liability Claims No CMS Policy No Regulations

9 Pay it Forward The Case for Class III & Liability Workers Compensation 42 CFR (b)(2) If a settlement appears to represent an attempt to shift to Medicare the responsibility for payment of medical expenses for the treatment of a workrelated condition, the settlement will not be recognized. Liability Claims 42 U.S.C. 1395y(b)(2) 42 U.S.C. 1395y(b)(2)(B)(ii) Medicare Secondary Payer Manual, Chapter 1, 20, defines LMSA MMSEA Town Hall Conference Call Statements

10 Pay it Forward Consequences of Not Acting CMS Invalidate Settlement CMS Suspends Medicare Benefits CMS Pays and Collects Payments as Conditional Payments Relates Back

11 Pay it Forward Take Reasonable Steps

12 Report It Two Responsibilities 42 CFR (Since 1989) Ignore implicates False Claims Act 42 CFR 1395y(b)(8) aka MMSEA Section 111 $1K Penalty Per Day ORM as of 01/01/2010 to CMS 01/01/2011. WC TPOC as of 10/1/2010 to CMS 01/01/2011 Liability TPOC as of 10/1/2011 to CMS 01/01/2012

13 Medicare Secondary Payer Reform Medicare Advocacy Recovery Coalition (MARC) Responsible for H.R. #4796, died end of last session New legislation to be introduced in a few weeks that will: Establish a 3 year limitations period Disallow use of SSN or HICN by Medicare Create appeal process for Primary Plan Establish a threshold Simplifies paying Medicare conditional payments Your Support is Needed Letters, Money or Both!

14 Medicare Secondary Payer Questions Roy A. Franco, Esq. Telephone: (716) ext. 137 Fax: (888) Referrals: Website: Address: 2746 Delaware Ave., Kenmore, NY Blog: