On March 2, 2018, the United States District Court for the Middle District of Florida, Orlando Division, published its opinion on MSPA Claims 1, LLC v. Halifax Health, Inc., in which the court found that a private right of action under the Medicare Secondary Payer Act, 42 U.S.C. §1395y(b) et seq. (MSP Act), which provides for double damages in the event of untimely reimbursement of Medicare payments in certain circumstances, is unavailable against providers of medical services. Based on such ruling, the court dismissed with prejudice claims that had been raised under the MSP Act against Halifax Hospital Medical Center, a public hospital based in Daytona Beach, Fla.
It has been a long time coming, two years to be exact. After the Centers for Medicare and Medicaid Services (CMS) announced their anticipated release of a solicitation for the Workers’ Compensation Review Contractor (WCRC) in 2016 and 2017 and further announced it was continuing to consider expanding its voluntary MSA review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts in 2016 and 2017, Medicare Secondary Payer (MSP) stakeholders never thought the day would come. But, after a challenge of the awarded contract and after several months during which Provider Resources continued to work under an expired contract, on March 7, 2018, CMS finally held the WCRC Transition Webinar to introduce Capitol Bridge, LLC, the new workers’ compensation review contractor.
Rafael Gonzalez, Esq. President, Flagship Services Group
On February 8, 2018, the National Council on Compensation Insurance (NCCI) published its MEDICARE SET-ASIDES AND WORKERS COMPENSATION— 2018 UPDATE (study), written by Nedžad Arnautović. The study can be found at https://www.ncci.com/Articles/Documents/II_MSA-WC-Study.pdf What follows is a verbatim rendition of the facts, analysis, findings and conclusions found in the report.
“In September 2014, NCCI published a study on Medicare Set-Asides (MSAs) in workers compensation. Using the sample of MSAs submitted to the Centers for Medicare & Medicaid Services (CMS) between September 2009 and November 2013 and completed between January 2010 and November 2013, the study examined several aspects related to Medicare Set Asides (MSAs), such as the distribution of amounts of MSAs and total settlements that include MSAs, claimants’ age distribution, the duration of time from submission to CMS approval, and the relation between submitted and CMS-approved MSA amounts. This paper provides an update and expansion of the previous MSA study using the larger data sample as well as additional experience from 2014 and 2015.”
Rafael Gonzalez, Esq., President, Flagship Services Group
After 35 years of seeking reimbursement of conditional payments post settlement, judgment, award, or payment of a case, in 2015, the Centers for Medicare & Medicaid Services (CMS) transitioned a portion of the Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). As a result, on October 5, 2015, the CRC assumed responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity, referred to as Applicable Plans (AP), as the identified debtor. Since then, CMS, through a contract with CGI, had been pursuing recovery directly from APs as the identified debtor when an applicable plan reports that it has ongoing responsibility for medicals (ORM) or otherwise notifies CMS of its primary payment responsibility.
On January 12, 2018, in the Circuit Court of the 11th Judicial Circuit in and for Miami Dade County, Florida, MSPA Claims 1 filed its motion for approval of a class action settlement against Ocean Harbor Casualty Insurance. The settlement agreement is intended by the parties to fully, finally, and forever resolve, discharge, and settle all claims. The motion indicates that the settlement agreement provides a fair, flexible, speedy, cost-effective, and assured monetary settlement to the class members. Thus, the settlement agreement provides considerable benefit to the class members while avoiding costly litigation of difficult and contentious issues. The parties also indicate that the settlement agreement is a compromise, and shall not be construed as, or deemed to be evidence of admission or concession of liability or wrongdoing on the part of Ocean Harbor with respect to any claim of any fault or liability or wrongdoing or damage whatsoever.
There are two vital rules you need to follow when it comes to managing risk:
- Never trust a lawyer.
- See Rule #1, especially when that lawyer’s interests are averse to yours.
Tongue-in-cheek aside, these rules make sense from a business perspective. Yet, when dealing with the matter of compliance to Medicare’s personal injury claims reporting and recovery guidelines, far too many insurance carriers routinely break these rules, often to their detriment.
As an insurance executive, you would never allow a claimant’s lawyer to come in and have free access to your claim data. Not only are they not experts in the necessary skills to handle your money, they also have a significant conflict of interests: their goal is to get as much money for their client – and, by extension, themselves – as possible. Read more
Statistically, Medicare-related claims make up around 10-15% of your total claims volume at any given time.
It doesn’t seem like much when you consider it in that light, so often busy insurance executives may fail to give Medicare compliance the emphasis it deserves. Here are some important reasons why both the CEO and the VP of Claims should bring Medicare compliance up a notch or two in their list of priorities.
It’s a money issue, not just a compliance issue.
Unlike the other risks insurance executives are used to, Medicare compliance can have a direct impact on the company’s bottom line.
Penalties for non-compliance are strong, and are becoming more readily assessed through more stringent and more frequently ordered auditing procedures. If the carrier is found to be non-compliant on a Medicare-related personal injury claim, fines can be as high as double the initial settlement amount, plus interest.
On higher-value claims, that kind of penalty can put a serious dent into annual financials. Read more
We’re going to jump up on our soapbox for a moment here, so bear with us.
We’ve noticed a common trend among our competitors that just really rubs us the wrong way. Many companies offering to handle Medicare compliance for P&C insurance carriers recommend focusing on the largest claims. Insurance carriers may even think this strategy is the industry standard.
But it’s not.
What we’re talking about is cherry picking the largest claims for Medicare compliance review and closure and ignoring the rest.
Now, it’s obvious why so many companies go this route: it takes less time, it provides impressive-looking results for the client, and it rakes in high profits for the company handling the Medicare claims. If you’re a smooth-enough talker, it can sound like a win-win for everyone involved.
But it’s NOT in the best interests of the insurance carriers. Here’s why:
This is the first in a two-part blog series involving the day-to-day role of a claims adjuster at the average P&C insurance carrier and how Flagship Services Group can make that day easier and more rewarding. In this post, we’ll look at some potential pitfalls the average claims adjuster is not going to want to deal with. In the next post, we’ll discuss how these pitfalls are avoided.
The average claims adjuster at a mid-size to large P&C insurance carrier – let’s call him Bob – has myriad tasks to handle throughout a given day.
Bob’s Busy Day
Bob starts the day listening to 14 voicemails that came in since he left the previous day. Three are from one particularly tenacious and obnoxious lawyer who enjoys trying to bully adjusters with crude language and a lot of bluff and bluster. The rest are from various claimants, attorneys, and other sources he’s been playing phone tag with for days now.
Next, over a cup of not-so-good coffee, Bob reviews his inbox to find two new files in his queue. This puts his total case load at 134 – not the worst he’s seen, but right up there. He sighs and pulls out a Post-It note to remind himself to make the obligatory contact call on each of these new claims before he leaves today since the 24-hour service standard will have expired before he gets in tomorrow.
This is the second in a two-part blog series involving the day-to-day role of a claims adjuster at the average P&C insurance carrier and how Flagship Services Group can make that day easier and more rewarding. In the last post, we looked at some potential pitfalls the average claims adjuster does not want to deal with. In this post, we’ll discuss how these pitfalls are avoided.
As we noted in the previous post, the average claims adjuster at a mid-size to large P&C insurance carrier has a heavy case load and a lot of stringent requirements and KPIs keeping them on their toes.
We were introduced to Bob, a P&C staff claims adjuster who just opened up a new file to find it’s one of those dreaded Medicare reimbursement cases. The claimant is a Medicare beneficiary who was injured in a motor vehicle accident and was in the hospital for several days. In addition, he has ongoing physical therapy and follow-up medical bills in the mix. Medicare has already paid for the hospitalization and a Conditional Payment Letter is on its way.
Now, Bob only sees one or two of these types of claims every month, in among as many as 200 claims he may touch in that same amount of time. As a result, he’s not completely comfortable with all the regulations involved, and he knows it’s going to take a lot of time to research it and get that all straight before he can proceed with confidence.