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NY Chapter - RIMS MMSEA Reporting & MSP Compliance. Medicare Compliance - Evolution. Passed in 1980: 42 USC 1395y and 42 CFR 411 Legislative Intent: Medicare will always be a “Secondary Payer” if a primary payer exists
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Medicare Compliance - Evolution • Passed in 1980: 42 USC 1395y and 42 CFR 411 • Legislative Intent: Medicare will always be a “Secondary Payer” if a primary payer exists • Primary Payers include: Workers’ Compensation, Liability, Auto No Fault, USL&H, Jones Act, and Group Health • In July of 2001, CMS introduced the MSA Review and Approval process for certain WC settlements • In December of 2007, SCHIP Extension Act was passed into law and affects claims that involve payments, settlements, judgements, awards with Medicare beneficiaries
Why the Mandatory Insurer Reporting? • Primary Purpose – Enforce MSP Compliance Requirements • CBO Assessment – plans to collect $1.1 Billion in fines from “Primary Payers” for non-compliance CIVIL MONEY PENALTY FOR FAILURE TO REPORT: $1,000.00 per day per claim • They intend to use the data to collect past payments • They intend to use the data to stop erroneous future payments
SCHIP Extension Act of 2007 • SCHIP makes NO CHANGES in the WC MSA Review and Approval Program • SCHIP is a separate and distinct program that runs in parallel with your WC MSA Program • SCHIP brings an additional step requiring mandatory reporting • May change the way you manage your Medicare risk
Conditional Payments • Requires that all Medicare “liens” are reimbursed in a timely manner • If not paid by claimant/plaintiff in 60 days post-settlement become the responsibility of the primary payer • US v. Harris • Medicare can recover double damages plus interest and attorney fees • Projected Trends with Conditional Payments - in 2010, 2011 & forward • Requires that “adequate consideration” of Medicare’s interest is shown in all settlements involving a Medicare Eligible claimant/plaintiff • Absent an allocation Medicare can recover the entire settlement amount • CMS - Past Recovery & Future Protection
Integrated Solution - Steps MSP Compliance & SCHIP Reporting Step One: Identify - MQF Step Two: Satisfy – CPR & LNS Step Three: Allocate Step Four: Report - MIR
G&L Contact Information Duke T. Wolpert, MSI, SCLA Vice President of Strategic Services Gould & Lamb, LLC 101 Riverfront Blvd., Suite 100 Bradenton, FL 34205 1-866-672-3453 Ext 1067 duke.wolpert@gouldandlamb.com www.gouldandlamb.com
