Medicare Risk Review
Internal Medicare claims management is time consuming and error-prone because the Federal regulations are complex and continuously changing. It is virtually impossible for individual claim adjusters to stay on top of on-going changes, but non-compliance can result in financial penalties and negative publicity.
What is Your Compliance Status?
For most P&C insurers, 10% – 15% of personal injury claims involve a Medicare beneficiary. Because the number of such claims is relatively small, they are typically managed at the claim adjuster desk. Many P&C insurers have not created systems for managing the process and tracking their overall compliance status, including:
- Identifying all Medicare beneficiaries (18% are under age 65);
- Complying with Section 111 Reporting obligations;
- Managing Conditional Payment reimbursements and rebuttals;
- Creating Medicare Set-Asides (MSAs) or alternative options;
- Securing Medicare beneficiary file closure documents.
What to Expect from Flagship’s MRR
Flagship’s proprietary Medicare Risk Review (MRR) eliminates the unknowns and provides an analysis of insurer’s Medicare compliance status, including processing procedures, potential Conditional Payment rebuttal savings, plus any non-compliance issues and/or penalty exposure. Additionally, Flagship identifies Medicare training needs for claim professionals that include performance measures and best practices for accelerating settlements, minimizing litigation and avoiding penalties.
Flagship is keenly aware of the most common, as well as the infrequent, non-compliance issues. We understand how to protect clients’ financial resources by minimizing reimbursements, mitigating penalties, ensuring compliance and accelerating settlement. A Medicare Risk Review removes the uncertainties surrounding Medicare compliance, and completes the steps required to close a Medicare file and create a valid audit trail. At the conclusion of an MRR, Flagship provides client with a comprehensive Executive Summary showing audit findings, solutions and recommended actions.
Components of an MRR include the following:
- Claim File Analysis
Review cross-section of Medicare claims including high dollar, no fault, litigated, settled and open claims.
- Claims Staff Interviews
Interviews with vertical slice of Claims Department, from managers and supervisors, to front-line claim adjusters.
- Medicare Essentials Training
Brief, but comprehensive, training session for claim professionals. Provides perspective on, and increases sensitivity to, the importance of accurate and timely Medicare claims processing.
- Louisiana Appellate Court Rules CMS Approval of MSA Was a Suspensive Condition that Suspended Obligation to Fund the MSA Until CMS Approval (5/21/2018) - Rafael Gonzalez, Esq. President, Flagship Services Group On May 2, 2018, the Third Circuit Court of Appeal of Louisiana published its opinion on Mary Ortega v. Cantu Services, Inc., concluding that the settlement of the workers compensation claim at hand was conditioned on CMS approval of a Medicare Set-Aside. Because the settlement agreement did not […]
- 6th Circuit Denies Beneficiary MSP Double Damages for Not Alleging Personal Financial Loss and Therefore Not Establishing Standing (5/15/2018) - On April 16, 2018, the United States Sixth Circuit Court of Appeals published its opinion on Gucwa and Marusza v. Lawley, Ager, Baker, Rubin and Accident Fund Insurance Company, finding that because Gucwa and Marusza did not allege personal financial loss in the original complaint or the two amended complaints, they have not established standing […]
- A Tale of Two Courts: Can MAPs Recoup MSP Double Damages from Medical Providers That Have Received Payment from Primary Payer? (4/23/2018) - Rafael Gonzalez, Esq. President, Flagship Services Group What a difference a couple of miles and a couple of days make. On March 2, 2018, the United States District Court for the Middle District of Florida, (Orlando), published its opinion on MSPA Claims 1, LLC v. Halifax Health, Inc., in which the court found that a […]