for your Casualty Program W W W . C H I C A G O L A N D R I S K F O - - PowerPoint PPT Presentation

W W W . C H I C A G O L A N D R I S K F O R U M . O R G

Developing Alternative & Strategic Approach to Medicare Compliance for your Casualty Program

Developing Alternative & Strategic Approach to Medicare Compliance for your Casualty Program

Presented by: Thomas S. Thornton, III Carr Allison 100 Vestavia Parkway Birmingham, AL 35216 tthornton@carrallison.com 205.949.2936 2 Presented by: Michael Chmielewski

Corporate Risk & Insurance Manager

Ace Hardware Corporation Chicago Illinois mchmi@acehardware.com Phone: 630-472-4961

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ORGANIZATIONAL CONCERNS

• Medicare’s impact upon program from both an increased cost

and administrative claim handling perspective

• Lack of clear direction and/or application of strategic claim

resolution options relating to Medicare compliance by: – TPA (whose interest are they protecting) – Carrier/excess (Are they invested in the decision) – Defense/Plaintiff’s attorneys (Do they understand the full MSP Act)

• What is a “Medicare Set Aside?

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ORGANIZATIONAL GOALS

• Achieve Claim Closure
• Remain Compliant with the

Medicare Act

• Avoid Unnecessary Spend

– Save money!

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Problems Plaguing The Industry

• Industry confusion with regard to complying with the Medicare

Act for both liability and workers’ compensation matters.

• Lack clearly defined and strategic approach to resolving cases

– Allowing Medicare to drive how we handle and evaluate our cases. – How we evaluate and handle our cases should drive how we respond to Medicare.

• Who is directing and managing the strategic Medicare

compliance response to non-litigated and litigated claims 5

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Where Should Compliance under Medicare Act Begin?

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Section 111 Reporting Identification and Timely Verification of Medicare Status

Timely & Appropriate Reimbursement

• f Liens (CPC)

Documenting and Addressing Medicare’s Future Interest (MSA)

Medicare Secondary Payer Act And Impact Upon Casualty Program

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Section 111 Reporting and Impact Upon Casualty Claim Programs!

• Potentially impacts all liability settlements where

consideration paid is in excess of $750.00 and the release was signed on or after January 1, 2017.

– Three questions to ask – Defense and Plaintiff’s Bar confusion

• Impact with Workers’ Compensation Claims and

Settlements:

– Ongoing Responsibility for Medicals has been assumed or assigned; – Settlement of indemnity/vocational; – Closure of Ongoing Responsibility for Medicals under state act

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Medicare Secondary Payer Act

And Impact Upon Casualty Program

Identification and Timely Verification of Medicare Status Timely & Appropriate Reimbursement of Conditional Payment Claims

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Protection/Reimbursement of Conditional Payment Claims

• Liability Claims

– Do not have to know CMS lien to evaluate and settle case

• Medicare’s lien does not arise until date release is signed

(Field 80 Date of TPOC

– Available strategies

• $750.00 or less waiver
• 25% Reimbursement option for claims valued between $750

and $5,000

• Assume vs Assign

– Pro Se vs Represented

• Workers’ Compensation Claims

– Purpose of Section 111 reporting – Denied claims

• Assume vs Assign

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Identification and Timely Verification of Medicare Status

Addressing Medicare’s Future Interest

Medicare Secondary Payer Act And Impact Upon Casualty Program

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Medicare’s Future Interest and Impact Upon Claim Handling

• Statutory Obligation Only Creates potential

Conditional Payment Lien Recovery by Medicare (42

USC 1395y : “Has or Had Responsibility)

• Submission is voluntary because of Due Process

Concerns

– No appellate avenue

• Medicare’s analysis when voluntarily applied is

unconstitutional

– Liability determined by medical conditions claimed and/ released or Medical bills paid (strict liability) – Lifetime expectation – Subjectivity, available defenses, and human element are not considered

• Arguable Standard:

– Where future accident related medical treatment is reasonably anticipated, appropriate allocation from settlement amount to reflect avoiding unreasonable burden shifting to CMS (42 CFR 411.46 ) 12

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Medicare’s Future Interest and Impact Upon Claim Handling

• Liability Cases:

– Allocate $0.00 where evidence substantiates that claimed accident related condition has resolved; (PRN, 90 Day Rule, Temporary nature of injury) – Allocate appropriate amount from settlement proceeds to reflect avoiding unreasonable burden shifting

• Workers’ Compensation Cases

– Analysis based upon claim value and exposure:

• Self Allocate vs Medicare Vendor Report based upon claim

value and CMS work review or otherwise established threshold

• Non-Submit vs Voluntary Submission of Report
• Medical cost projection report vs. CMS mandated analysis of

MSA 13

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Casualty Program + Medicare Compliance

– Identify Internal Goals within own Program – Invest in understanding risk vs cost vs reward marrying Program Goals with Medicare compliance

• Medical Cost Projection vs Traditional Allocation Report
• Non-Submit vs Voluntary Submit

– Identify partners to help implement and manage compliance

• TPAs, carriers and Medicare vendor

– Redefine the boxes which are checked by those managing your claims through Standard Operating Procedures with checks and balances

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QUESTIONS?

Presented by: Thomas S. Thornton, III Attorney Carr Allison tthornton@carrallison.com 205-949-2936

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