Medicare Conditional Payment and Medicare Advantage Plan...
Transcript of Medicare Conditional Payment and Medicare Advantage Plan...
The audio portion of the conference may be accessed via the telephone or by using your computer's
speakers. Please refer to the instructions emailed to registrants for additional information. If you
have any questions, please contact Customer Service at 1-800-926-7926 ext. 10.
Presenting a live 90-minute webinar with interactive Q&A
Medicare Conditional Payment and Medicare
Advantage Plan Reconciliation Processes Techniques to Minimize Repayment Obligations and
Maximize Medicare Refunds After a Liability Settlement
Today’s faculty features:
1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific
WEDNESDAY, DECEMBER 13, 2017
David L. Place, JD, Vice President, Director of Lien Resolution Services,
Synergy Settlement Services, Culpeper, Va.
Tips for Optimal Quality
Sound Quality
If you are listening via your computer speakers, please note that the quality
of your sound will vary depending on the speed and quality of your internet
connection.
If the sound quality is not satisfactory, you may listen via the phone: dial
1-866-869-6667 and enter your PIN when prompted. Otherwise, please
send us a chat or e-mail [email protected] immediately so we can
address the problem.
If you dialed in and have any difficulties during the call, press *0 for assistance.
Viewing Quality
To maximize your screen, press the F11 key on your keyboard. To exit full screen,
press the F11 key again.
FOR LIVE EVENT ONLY
Continuing Education Credits
In order for us to process your continuing education credit, you must confirm your
participation in this webinar by completing and submitting the Attendance
Affirmation/Evaluation after the webinar.
A link to the Attendance Affirmation/Evaluation will be in the thank you email
that you will receive immediately following the program.
For additional information about continuing education, call us at 1-800-926-7926
ext. 35.
FOR LIVE EVENT ONLY
Program Materials
If you have not printed the conference materials for this program, please
complete the following steps:
• Click on the ^ symbol next to “Conference Materials” in the middle of the left-
hand column on your screen.
• Click on the tab labeled “Handouts” that appears, and there you will see a
PDF of the slides for today's program.
• Double click on the PDF and a separate page will open.
• Print the slides by clicking on the printer icon.
FOR LIVE EVENT ONLY
MEDICARE CONDITIONAL PAYMENTS, MEDICARE ADVANTAGE & HOW TO OBTAIN MEDICARE REFUNDS DAVE PLACE, J.D. VICE PRESIDENT, SYNERGY SETTLEMENT SERVICES DIRECTOR SYNERGY LIEN RESOLUTION SERVICES
Medicare Conditional Payments
6
Have your client sign two necessary forms to allow access to his/her Medicare information.
Form A: Proof of Representation https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group-Health-Plan-Recovery/Downloads/ProofofRepresentation.pdf Form B: Consent to Release http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group-Health-Plan-Recovery/Downloads/ConsenttoRelease.pdf
The Proof of Representation allows the attorney to act on behalf of the beneficiary. For example, this allows the attorney to negotiate the lien. The Consent to Release allows Medicare to provide information to the attorney. For example, this allows Medicare to send the attorney the payout log.
Step 1 – Forms
7
Medicare Forms
8
Medicare Forms
9
Report your claim to the Benefits Coordination & Recovery Center (BCRC) for Medicare. You can report one of two ways, by telephone 1-855-798-2627 where you can report up to eight claims at a time or by mail to:
MEDICARE-MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897
Step 2 - Notice
10
• Beneficiary Information – Beneficiary's Name – Medicare HIC Number – Beneficiary's Insurer Name & Address – Beneficiary's Health Insurance Claim Number – Beneficiary's Gender & Date of Birth – Beneficiary's Address & Phone Number
• Case Information – Date of Injury – Description of Alleged Injury or Illness or Harm – Type of Claim (Liability Insurance, No-Fault Insurance) – Defendant's Name – Defendant's Insurer Name & Address – Defendant's Claim Number & Policy Number
• Representative Information – Representative/Attorney Name – Law Firm Name – Address & Phone Number
What to Include in Notice
11
12
• Medicare will respond to notice within 14 days.
• You will need to make sure all the information contained in this letter is correct. If it is not, you will need to fill it out accordingly, and send it back to the address on the letter.
• If you do not receive this letter, then you will need to re-submit your documentation.
• From this point on, you will need to send a Correspondence Cover Sheet with any correspondence to Medicare.
• The Correspondence Cover Sheet can be found here: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group-Health-Plan-Recovery/Downloads/MSPRC-NGHP-Correspondence-Cover-Sheet.pdf
Step 3 – Rights and Responsibilities
13
BCRC Cover Sheet used to ensure proper routing of correspondence
Medicare Forms
14
• Sent within 65 days of receiving your Rights and Responsibilities Letter. This letter will list all the claims related to the injuries.
• Conduct an audit of the Conditional Payment Summary
– Provider Name
– Diagnosis Codes
– From-To Dates
– Total Charges
Step 4 – Conditional Payment Summary
15
• If unrelated charges are on the Conditional Payment Summary you can request that BCRC remove them. – Contact Medicare noting which claims are not
related and why. – If the injury claimed is complex in nature, provide
medical records to support your dispute – Do not use a highlighter as Medicare scans their
documents in and thus highlighting does not show up.
– Don't forget to send your Correspondence Cover Sheet
Step 5 - Dispute
16
MSPRP Portal - Dispute
17
Medicare Conditional Payments –
Optional Process Final Conditional Payment
18
MSPRP Portal – Final Conditional Payment Process
19
MSPRP Portal – Final Conditional Payment Process
120 Notice of Settlement
20
MSPRP Portal – Final Conditional Payment Process
21
MSPRP Portal – Final Conditional Payment Amount
22
MSPRP Portal – Electronic Final Conditional Payment Letter
23
MSPRP Portal – Electronic Final Conditional Payment Letter
24
MSPRP Portal – Final Conditional Payment Process
120 Notice of Settlement
25
MSPRP Portal – Final Conditional Payment Process
26
• Once you settle your case advise Medicare. • Download the "Final Settlement Detail Document“
– http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group-Health-Plan Recovery/Downloads/Final_Settlement_Detail.pdf
– Provide the information on company letterhead – Total amount of the settlement – Total Amount of Med-Pay or PIP – Attorney Fee Amount paid by the beneficiary – Additional Procurement Expenses Paid by the Beneficiary
• Attached itemized list of these expenses
– Date the Case was Settled
Step 6 – Final Demand Letter
27
Medicare Forms – Final Settlement Detail Document
28
MSPRP Portal – Final Demand Request
29
• C.F.R. 411.37(c) – Medicare payments are less than the judgment or settlement.
• Add (Attorney’s Fees) and (Costs) = Total Procurement Costs • (Total Procurement Costs) / (Gross Settlement Amount) = Ratio • Multiply (Lien Amount) by (Ratio) = Reduction Amount • (Lien Amount) - (Reduction Amount) = Medicare Demand Amount
• C.F.R. 411.37(d)
– Medicare payments are equal to or exceed the judgment or settlement. • Add (Attorney’s Fees) and (Costs) = Total Procurement Costs • (Gross Settlement Amount) - (Total Procurement Costs) = Medicare
Demand Amount
Calculations
30
You must pay this demand amount within 60 days or the lien will accrue interest.
Request for Appeal or Waiver does not toll interest.
Interest is due and payable for each full 30 day period the debt remains unresolved.
By law all payments are applied to interest first, principal second.
42 C.F.R.411.24(m)
After receiving payment, Medicare will send a letter stating the lien has been reduced to zero and the case is closed.
Pay or Else!
31
• Appeal
• Financial Hardship Waiver
• Compromise
• “Best Interest of the Program” Waiver
Medicare Conditional Payments Post Final Demand Options
32
33
Appeals
APPEAL LEVEL TIME LIMIT FOR FILING
REQUEST
MONETARY THRESHOLD TO BE
MET
I. Redetermination 120 days from date of receipt of
the notice initial determination
None
2. Reconsideration 180 days from date of receipt of
the redetermination
None
3. Administrative Law Judge
(ALJ) Hearing 60 days from the date of
receipt of the
reconsideration
At least $130 remains in
controversy.
4. Departmental Appeals Board (DAB) Review/Appeals Council
60 days from the date of receipt
of the ALJ hearing decision
None
5. Federal Court Review 60 days from date of receipt of
the Appeals Council decision or
declination of review by DAB
At least $1 ,260 remains in
controversy.
34
Involves application for a compromise or waiver to both the Benefits Coordination and Recovery Center (BCRC) as well as the Center for Medicare and Medicaid Services (CMS) There are three statutory authorities under which Medicare may accept less than the full amount of its claim:
§1870(c) of the Social Security Act – BCRC (Financial Hardship Waiver) §1862(b) of the Social Security Act – CMS (Best Interest of the Program Wavier) The Federal Claims Collection Act (FCCA) – done by CMS (Compromise)
**If successful, a refund is issued by Medicare**
Post Payment of Final Demand Waiver/Compromise
35
• §1870(c) of the Social Security Act;
• Pay the Final Demand amount and then attempt to obtain a partial or full waiver.
• Waiver of recovery should not be requested until the case is settled and Medicare has issued a demand for repayment letter.
• Requests for waiver must be submitted in writing
• Medicare may grant a full or partial waiver if recovery would negatively affect the beneficiary's standard of living compared to how it was before the accident/injury/illness.
Financial Hardship Waiver
36
“There shall be no recovery if such recovery would defeat the purposes of this chapter or would be against equity and good conscience.”
The Medicare Secondary Payer Manual does provide example situations of financial hardship that would justify a full or partial waiver consideration. “The beneficiary has spent the settlement proceeds and the only remaining income from which the beneficiary could attempt to satisfy Medicare’s claim would be from the money that is needed for the beneficiary’s monthly living expenses; Beneficiary income and resources are at a poverty level standard An unforeseen severe financial circumstance- For example, waiver would be appropriate if the beneficiary became legally responsible for their grandchildren.”
Financial Hardship Waiver
37
A Medicare beneficiary seeking a waiver or compromise of Medicare’s interest is required to submit a Hardship Letter to CMS for
use in their evaluation process. Whenever possible this letter should be written by the beneficiary. The letter needs to express to
CMS why repaying Medicare the amount of their Final Demand is “against equity and good conscience” and has/will create(d) an
“undue hardship”.
1. Facts of Accident
2. Injuries – Physical, psychological, emotional
3. Current Physical, Mental, Emotional state
4. Unrecorded out of pocket expense
a. House Renovation
b. Adult diapers
c. Prescriptions
d. Private nurse or custodial care not paid by Medicare
e. Co-insurance and deductible
f. Accident related dental work
g. Other financial obligations
5. Status of settlement proceeds. Exhausted?
6. Unforeseen financial circumstances---ex. become legally responsible for grandchildren.
7. Degree to which repayment would cause undue hardship
8. Reason why repayment is not justified.
Hardship Letter
38
• The Federal Claims Collection Act (FCCA) CMS may suspend or end collection action on a claim when it appears that no person liable on the claim has the present or prospective ability to pay a significant amount of the claim or the cost of collecting the claim is likely to be more than the amount recovered. – The cost of collection does not justify the enforced
collection of the full amount of the claim; – There is an inability to pay within a reasonable time
on the part of the individual against whom the claim is made; or
– The chances of successful litigation are questionable, making it advisable to seek a compromise settlement.”
Post-Settlement Compromise
39
• § 1862(b) of the Social Security Act;
• A separate and distinct evaluation than a request under §1870(c) of the Social Security Act (Financial Hardship Wavier) and a request for a Compromise under the Federal Claims Collection Act (FCCA)
• The Secretary may waive (in whole or in part) the provisions of this subparagraph in the case of an individual claim if the Secretary determines that the waiver is in the best interests of the program established under this title
“Best Interest of the Program” Waiver
40
MAO Plans
41
• Medicare Advantage Plans, sometimes called “Part C” or “MAO,” are offered by private companies approved by Medicare. The MAO Plan provides all of Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. MAO Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Medicare pays a fixed amount for your care every month to the companies offering MAO Plans. These companies must follow rules set by Medicare.
• As Medicare Advantage plans are administered by private insurance companies many of the difficulties that dealing with BCRC or CMS can entail are avoided. Though these plans arguably have the same recovery rights as traditional Medicare, they are often much more open to agreements based upon equity and fairness
• MAO Plans use the Medicare Secondary Payer Act as their recovery vehicle.
Medicare Advantage
42
• The Medicare Secondary Payer Act (MSP) provides for a private cause of action when a primary plan fails to reimburse a secondary plan for conditional payments it has made.
“there is established a private cause of action for damages (which shall be in an amount double the amount otherwise provided) in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement) in accordance with paragraphs (1) and (2)(A).” - 42 U.S.C. § 1395y(b)(3)(A).
• 42 C.F.R. §422.108(f) extends the private cause of action to Medicare Advantage Plans.
“MAOs will exercise the same rights to recover from a primary plan, entity, or individual that the Secretary exercises under the MSP regulations in subparts B through D of part 411 of this chapter.”
• Additionally, CMS directors have issued memorandum asserting that:
“notwithstanding recent court decisions, CMS maintains that the existing MSP regulations are legally valid and an integral part of Medicare Part C and D programs.” - CMS, HHS Memorandum: Medicare Secondary Payment Subrogation Rights (Dec. 5, 2011).
Medicare Advantage – Recovery Rights
43
• Medicare Advantage Plans will use the same statutory formula to calculate their repayment as CMS (Centers for Medicare and Medicaid Services).*
• C.F.R. 411.37(c)
• Medicare payments are less than the judgment or settlement.
• Add (Attorney’s Fees) and (Costs) = Total Procurement Costs
• (Total Procurement Costs) / (Gross Settlement Amount) = Ratio
• Multiply (Lien Amount) by (Ratio) = Reduction Amount
• (Lien Amount) - (Reduction Amount) = Medicare Demand Amount
• C.F.R. 411.37(d)
• Medicare payments are equal to or exceed the judgment or settlement.
• Add (Attorney’s Fees) and (Costs) = Total Procurement Costs
• (Gross Settlement Amount) - (Total Procurement Costs) = Medicare Demand Amount
* Not all Medicare Advantage Plans agree that they are subject to these reduction regulations. Rawlings advocates this position.
Medicare Advantage – Repayment Formula
44
• In Humana Medical Plan, Inc. v. Western Heritage Ins. Co., No. 15-11436 (11th Cir. Aug. 8, 2016), the 11th Circuit Court of Appeals affirmed the U.S. District Court for the Southern District of Florida granting of Humana's Motion for Summary Judgment and held that Humana's right to reimbursement for the conditional payments it made on behalf of plan beneficiary under a Medicare Advantage Plan was enforceable. Additionally, Humana was entitled to double damages pursuant to 42 U.S.C. § 1395y(b)(3)(A).
• Western Heritage had an obligation to independently reimburse
Humana. Because it didn’t, the Court rule that as a matter of law, Humana is entitled to maintain a private cause of action for double damages pursuant to 42 U.S.C. § 1395y(b)(3)(A) and is therefore entitled to $38,310.82 in damages.
• The Eleventh Circuit said that placing the $19,155.41 in trust was not
the same as paying the MAO and that the damages “SHALL” be double.
Medicare Advantage - All Eyes on Florida
45
• 42 U.S.C. § 1395y(b)(2)(B)(iii) “In order to recover payment made under this subchapter for an item or service, the United States may bring an action against any or all entities that are or were required or responsible … to make payment with respect to the same item or service … under a primary plan. The United States may … collect double damages against any such entity. In addition, the United States may recover under this clause from any entity that has received payment from a primary plan or from the proceeds of a primary plan’s payment to any entity.”
• 42 C.F.R. §411.24(g) “CMS has a right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician, attorney, State agency or private insurer that has received a primary payment.”
– United States v. Weinberg, 2002 U.S. Dist. LEXIS 12289 (E.E. Pa. July 1, 2002).
– United States v. Harris, 2009 U.S. Dist. LEXIS 23956 (N.D. W. Va. March 26, 2009) affirmed, 334 F. App’x 569 (4th Cir. 2009).
– Denekas v. Shalala, 943 F. Supp. 1073 (S.D. Iowa 1996).
Medicare Advantage – Attorney Liability
46
Medicare Advantage – Attorney Liable
47
Fighting the Good Fight Pays Off!
48
• Percent of “savings” based fee model – 10% of the “savings” (reduction) - Premier Client rate.
• We add value or we don’t take a fee. – If we don’t at least save your client the $500 advance fee
we refund it. – No advance fee for our Medicare Refund service.
• The injury victim comes first. – Synergy caps its fee at 10% of the plaintiffs’ net (after fees,
costs, and repaying any liens) – Premier Client rate.
• Motivated case managers. – Case managers receive bonuses depending on the amount
of “savings” they obtain.
“Plaintiffcentric” Pricing
49
Dave L. Place, J.D. Vice President, Director of Synergy Lien Resolution Services [email protected] 407-279-4811
THANK YOU