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A Practical Approach to MSP

A Practical Approach to MSP. Charleston County Bar February 14, 2014. Overview. Medicare Insurance Worker’s Compensation Insurance Medicare Secondary Payer Regulations Cost Projections Affordable Care Act Preparing for Settlement Settlement Language Roadblocks to Successful Settlements

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A Practical Approach to MSP

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  1. A Practical Approach to MSP Charleston County Bar February 14, 2014

  2. Overview • Medicare Insurance • Worker’s Compensation Insurance • Medicare Secondary Payer Regulations • Cost Projections • Affordable Care Act • Preparing for Settlement • Settlement Language • Roadblocks to Successful Settlements • Post Settlement Issues ProjectWorks

  3. Who Am I? • Registered Nurse • Certified Nurse Life Care Planner • Medicare Specialist Certified Consultant • Legal Nurse Consultant • Certified Disability Management Specialist • Certified Case Manager • Certified Insurance Rehabilitation Specialist ProjectWorks

  4. Experience • 15 years clinical and community health nursing • 15 years medical case management nursing • 15 years legal nurse consulting and life care planning • 5 years Medicare compliance ProjectWorks

  5. Team • Jenny Glasgow • Medical Case Manager ProjectWorks • Shawn Davis • Paralegal Joye Law Firm ProjectWorks

  6. Your Class • Ask/answer questions of me • Ask/answer questions of each other • Offer comments • Bring your own experiences to this seminar • A lot of information today ProjectWorks

  7. Who are you? • How many represent plaintiff clients • How many represent carrier/defense • How many work only cases in SC • How many work cases outside SC ProjectWorks

  8. Pop Quiz • Define and explain: • MSP LOR • SMART COB • CHIP MSPRC • ANPRM R&R • WCMSA LR • LMSA CMS • ACA HELP ProjectWorks

  9. Scoring • If can answer less than 5, need to stay for full class • If can answer 5-10, can use texting while in class • If can answer 10-13, will be called upon to help teach • If can answer all 14, provide contact information ProjectWorks

  10. Part 1 MEDICARE INSURANCE ProjectWorks

  11. Medicare Insurance • Eligibility • Age • Disability • Certain medical conditions • Premiums • Part A • Part B • Part D • Medigap ProjectWorks

  12. General Coverage • Hospital, with per occurrence and daily co-pays • Skilled nursing facility, with co-pays after 20 days • Home health, skilled services only • Medical office visits, with 80/20 co-pays • Physical & occupational therapy, with 80/20 co-pays • Durable medical equipment, with 80/20 co-pays • Diagnostics, with 80/20 co-pays • Counseling, with 65/35 co-pays ProjectWorks

  13. Medications • Significant co-pays • Significant deductibles • Significant exclusions ProjectWorks

  14. Fee Schedule • Medicare fee schedule • Some physicians not accepting Medicare rates • Billed rate, then adjustments on paid rate • 80% of Medicare rate ProjectWorks

  15. Not covered • TNS unit and supplies • Bathroom equipment • Home attendant care • Transportation • Some wheelchair equipment • Dental services • Vision and hearing services and equipment • Podiatry visits ProjectWorks

  16. Handout #1 • Chart on Medicare coverage ProjectWorks

  17. Part 2 WORKERS COMPENSATION INSURANCE ProjectWorks

  18. WC Insurance • Payment of all inpatient treatment • Payment of all outpatient treatment • Payment of prescription drugs • Payment of durable medical equipment ProjectWorks

  19. WC • Payment of all required premiums • Employers buy insurance from WC carriers • Employers are self insured • State Accident Fund ProjectWorks

  20. WC • No co-pays • No deductibles • No exclusions ProjectWorks

  21. WC • Claim’s administration • Pays bills • Schedules appointments • Reports to CMS • Negotiates rates • Authorizes treatment • Case management ProjectWorks

  22. WC • Each state has its own WC fee schedule • Differs from Medicare fee schedule • Differs from group health insurance fee schedule • SC WC fee schedule updates about every 5 years • Providers offer additional discounts to WC carriers ProjectWorks

  23. WC • Medical mileage reimbursement • Transportation to/from medical appointments • Pays for out of pocket expenses ProjectWorks

  24. Summary • Medicare covers whole body but has co-pays and deductibles • Workers Compensation has no co-pays and deductibles but covers injury related parts only ProjectWorks

  25. Part 3 MEDICARE SECONDARY PAYER ProjectWorks

  26. MSP • MSP regulations, 1980 • Medicare Secondary Payer • SMART Act, January 2013 • Strengthening Medicare and Repaying Taxpayers • ANPRM, October 2013 • Advanced Notice of Proposed Rule Making cms.gov ProjectWorks

  27. MSP • Says Medicare is secondary to all other insurances and medical funding, including settlements • Group health insurance • VA benefits • Workers Compensation • Auto liability insurance • Any liability coverage • Settlements ProjectWorks

  28. Secondary • …for past medical payments • …for current treatment • …for future medical care ProjectWorks

  29. MSP • Who is impacted • Class 1: already a Medicare beneficiary • Class 2: going to be a Medicare beneficiary within 30 months ProjectWorks

  30. MSP • CMS will do a pre-settlement review: • Already a Medicare beneficiary and settlement $25,000 or more (Class 1) • Going to be a Medicare beneficiary within 30 months and settlement $250,000 or more (Class 2) ProjectWorks

  31. MSP • Post-settlement review for all cases • CMS very often wants more than MSA allocation • How to handle this • Who is responsible for additional monies • Settlement language ProjectWorks

  32. MSP • Impacts Worker’s Compensation cases • Impacts Liability cases ProjectWorks

  33. MSP • Affects all parties • Insurance carriers • Defense attorneys • Plaintiff attorneys • Claimants • Physicians and providers ProjectWorks

  34. Handout #2 • 4 questions to ask each and every client ProjectWorks

  35. Universal Precautions • Consider each case as being impacted until proven not to be • Categorize each case as: • Not impacted • Class 1 • Class 2 ProjectWorks

  36. Do • Add 4 questions to intake sheet • Add 4 questions to settlement checklist • Be mindful of age and hitting the 62.5 mark ProjectWorks

  37. Do • Continuously update records with information • Insurance coverage • Application to SSDI • Application to SSI • Medicaid eligibility • Medicare eligibility • Social Security Administration correspondence ProjectWorks

  38. Do • Obtain copies of all insurance cards ProjectWorks

  39. Do • Sign in-house medical authorization • Sign CMS authorization ProjectWorks

  40. Do • Look at internal file management systems • Look at daily work flow • Look at computer management programs ProjectWorks

  41. Do • Look at contract language • Do you need to add anything to clarify • Additional expenses for experts • Reporting requirements • Other case costs specific to MSP • Outsourcing to experts ProjectWorks

  42. Do • Start educating client from day 1 on settlement impact of MSP ProjectWorks

  43. Do • Plaintiff and defense work together to obtain all necessary reporting information for CMS ProjectWorks

  44. Break • Questions • Comments • Discussion This was the easy stuff ProjectWorks

  45. More MSP • Regulations require reasonable consideration for future medical treatment • Regulations require reasonable consideration for future prescriptions • Pay back of any/all conditional payments made ProjectWorks

  46. Shawn Davis • Paralegal with Joye Law Firm • Conditional payments her “specialty” Contact: Joye Law Firm: 843.725.4279 sdavis@joyelawfirm.com ProjectWorks

  47. Conditional Payments • Set up claim with Medicare Coordination of Benefits (COB) and provide a copy of letter to MSPRC. These are two different offices. • Include as attachments the signed Consent to Release and Proof of Representation forms (available on Medicare’s website). ProjectWorks

  48. Rights and Responsibilities • Be sure the R&R letter includes the correct claim and/or policy number • Will also provide you with a Case ID Number ProjectWorks

  49. Case ID Number • Case ID Number is the “key” to the claim • All treatment-related claims are filed under this Case ID Number • All correspondence to Medicare should reference this Case ID Number • Contact Medicare if receive correspondence with more than one Case ID Number to get all claims moved to the correct case • Make sure other cases are closed ProjectWorks

  50. Requesting Conditional Lien • Notify Medicare of all treatment-related claims by provider, date of service, and total charge amount • Request specifically a “conditional lien amount” to avoid getting a final demand amount • Be sure to review all claims outlined in the conditional lien letter from Medicare to ensure related to injury • Send a Notice of Dispute to Medicare for any unrelated claims ProjectWorks

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