Medicaid & Medicare Pract actice ce Tips Eisenberg, Gilchrist - - PowerPoint PPT Presentation

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Medicaid & Medicare Pract actice ce Tips Eisenberg, Gilchrist - - PowerPoint PPT Presentation

Jan 02, 2024 664 likes •949 views

Medicaid & Medicare Pract actice ce Tips Eisenberg, Gilchrist & Cutt Candace Gleed Damian Huntsman (801) 366-9100 www.egclegal.com Medicaid Insurance provided by the State of Utah Financial need / disability / low-income

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Medicaid & Medicare Pract actice ce Tips

Eisenberg, Gilchrist & Cutt Candace Gleed Damian Huntsman (801) 366-9100 www.egclegal.com

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Medicaid

  • Insurance provided by the State of Utah
  • Financial need / disability / low-income
  • Statutory requirement to notify of any Third Party Liability
  • Medicaid – Initial Notification
  • Name
  • Date of Birth
  • Medicaid Insured Number
  • Attorney Information
  • Date of Injury / Loss
  • Short description of injury / claim
  • Responsible party
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Medicaid Cont.

  • Collection Agreement for signature by attorney, injured party
  • Letter containing adjuster information
  • Ledger of claimed Lien / Subrogation
  • Requests for periodic updates for ongoing care by client
  • Mediation / Settlement
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First Initial Medicare Letter

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Medicare Important Facts

  • Medicare Parts A, B, C, D (and gap insurance for international

coverage)

  • Part A –Covers hospital, home health, long-term care
  • Part B – Covers everything else, physician charges, PT, DME, etc.
  • Administered by CMS – BRBC
  • Part C – Supp Insurance cover co-pays, deductibles, etc.
  • Part D – Pharmacy
  • Administered by private insurance companies
  • All programs require reimbursement and notification
  • 42 CFR 411.24
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3 Types of Cases for Reporting

  • Liability
  • At-fault Liability Claims / Policies
  • Underinsured Claims / Policies
  • Uninsured Claims / Policies
  • No-Fault Insurance
  • Personal Injury Protection
  • Med Pay
  • Worker’s Compensation
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Plaintiff / Defense

  • Section 111 Requires Reporting by Insurance Payers
  • Current $750 threshold to report
  • Penalties for non-reported cases $1,000 per day per violation
  • Requires ICD-9 and ICD-10 codes on the report
  • Defense required reporting of PIP / medpay claims
  • Not available to Plaintiffs or beneficiary unless a release is signed
  • Can affect payment of claims relating to injury
  • Beneficial for Plaintiffs to review codes / req from adjuster or defense
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Conditional Payments

  • BRBC
  • Liability cases
  • Plaintiff / Beneficiary
  • Primarily Liability and Workers Compensation cases
  • CRC
  • No-fault cases
  • Insurance Payors / Defense
  • Contractor with claim will handle all disputes, payments, etc.
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  • Open only one case with Medicare for each applicable claim.
  • If a claim for Liability / UIM run consecutive two cases are required to be
  • pen
  • Use same language to describe injuries in correspondence, cover sheets, etc.

to prevent confusion, duplicate cases opened, or unrelated charges being added to lien ledger

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CMS.gov Reporting Guidelines

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Medicare – Letter / Notice of Case

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MSPRP Features & Benefits

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Final Demand

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