Presenting a live 90-minute webinar with interactive Q&A Medicare Conditional Payment and Medicare Advantage Plan Reconciliation Processes Techniques to Minimize Repayment Obligations and Maximize Medicare Refunds After a Liability Settlement WEDNESDAY, DECEMBER 13, 2017 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific Today’s faculty features: David L. Place, JD, Vice President, Director of Lien Resolution Services, Synergy Settlement Services , Culpeper, Va. The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10 .
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MEDICARE CONDITIONAL PAYMENTS, MEDICARE ADVANTAGE & HOW TO OBTAIN MEDICARE REFUNDS DAVE PLACE, J.D. VICE PRESIDENT, SYNERGY SETTLEMENT SERVICES DIRECTOR SYNERGY LIEN RESOLUTION SERVICES
Medicare Conditional Payments 6
Step 1 – Forms Have your client sign two necessary forms to allow access to his/her Medicare information. Form A: Proof of Representation https://www.cms.gov/Medicare/Coordination-of-Benefits-and- Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group-Health-Plan- Recovery/Downloads/ProofofRepresentation.pdf Form B: Consent to Release http://www.cms.gov/Medicare/Coordination-of-Benefits-and- Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group-Health-Plan- Recovery/Downloads/ConsenttoRelease.pdf The Proof of Representation allows the attorney to act on behalf of the beneficiary. For example, this allows the attorney to negotiate the lien. The Consent to Release allows Medicare to provide information to the attorney. For example, this allows Medicare to send the attorney the payout log. 7
Medicare Forms 8
Medicare Forms 9
Step 2 - Notice Report your claim to the Benefits Coordination & Recovery Center (BCRC) for Medicare. You can report one of two ways, by telephone 1- 855-798-2627 where you can report up to eight claims at a time or by mail to: MEDICARE-MSP General Correspondence P.O. Box 138897 Oklahoma City, OK 73113-8897 10
What to Include in Notice • Beneficiary Information – Beneficiary's Name – Medicare HIC Number – Beneficiary's Insurer Name & Address – Beneficiary's Health Insurance Claim Number – Beneficiary's Gender & Date of Birth – Beneficiary's Address & Phone Number • Case Information – Date of Injury – Description of Alleged Injury or Illness or Harm – Type of Claim (Liability Insurance, No-Fault Insurance) – Defendant's Name – Defendant's Insurer Name & Address – Defendant's Claim Number & Policy Number • Representative Information – Representative/Attorney Name – Law Firm Name – Address & Phone Number 11
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Step 3 – Rights and Responsibilities • Medicare will respond to notice within 14 days. • You will need to make sure all the information contained in this letter is correct. If it is not, you will need to fill it out accordingly, and send it back to the address on the letter. • If you do not receive this letter, then you will need to re-submit your documentation. • From this point on, you will need to send a Correspondence Cover Sheet with any correspondence to Medicare. • The Correspondence Cover Sheet can be found here: https://www.cms.gov/Medicare/Coordination-of-Benefits-and- Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group- Health-Plan-Recovery/Downloads/MSPRC-NGHP-Correspondence-Cover- Sheet.pdf 13
Medicare Forms BCRC Cover Sheet used to ensure proper routing of correspondence 14
Step 4 – Conditional Payment Summary • Sent within 65 days of receiving your Rights and Responsibilities Letter. This letter will list all the claims related to the injuries. • Conduct an audit of the Conditional Payment Summary – Provider Name – Diagnosis Codes – From-To Dates – Total Charges 15
Step 5 - Dispute • If unrelated charges are on the Conditional Payment Summary you can request that BCRC remove them. – Contact Medicare noting which claims are not related and why. – If the injury claimed is complex in nature, provide medical records to support your dispute – Do not use a highlighter as Medicare scans their documents in and thus highlighting does not show up. – Don't forget to send your Correspondence Cover Sheet 16
MSPRP Portal - Dispute 17
Medicare Conditional Payments – Optional Process Final Conditional Payment 18
MSPRP Portal – Final Conditional Payment Process 19
MSPRP Portal – Final Conditional Payment Process 120 Notice of Settlement 20
MSPRP Portal – Final Conditional Payment Process 21
MSPRP Portal – Final Conditional Payment Amount 22
MSPRP Portal – Electronic Final Conditional Payment Letter 23
MSPRP Portal – Electronic Final Conditional Payment Letter 24
MSPRP Portal – Final Conditional Payment Process 120 Notice of Settlement 25
MSPRP Portal – Final Conditional Payment Process 26
Step 6 – Final Demand Letter • Once you settle your case advise Medicare. • Download the "Final Settlement Detail Document“ – http://www.cms.gov/Medicare/Coordination-of-Benefits- and-Recovery/Coordination-of-Benefits-and-Recovery- Overview/Non-Group-Health-Plan Recovery/Downloads/Final_Settlement_Detail.pdf – Provide the information on company letterhead – Total amount of the settlement – Total Amount of Med-Pay or PIP – Attorney Fee Amount paid by the beneficiary – Additional Procurement Expenses Paid by the Beneficiary • Attached itemized list of these expenses – Date the Case was Settled 27
Medicare Forms – Final Settlement Detail Document 28
MSPRP Portal – Final Demand Request 29
Calculations • C.F.R. 411.37(c) – Medicare payments are less than the judgment or settlement. • Add (Attorney’s Fees) and (Costs) = Total Procurement Costs • (Total Procurement Costs) / (Gross Settlement Amount) = Ratio • Multiply (Lien Amount) by (Ratio) = Reduction Amount • (Lien Amount) - (Reduction Amount) = Medicare Demand Amount • C.F.R. 411.37(d) – Medicare payments are equal to or exceed the judgment or settlement. • Add (Attorney’s Fees) and (Costs) = Total Procurement Costs • (Gross Settlement Amount) - (Total Procurement Costs) = Medicare Demand Amount 30
Pay or Else! You must pay this demand amount within 60 days or the lien will accrue interest. Request for Appeal or Waiver does not toll interest. Interest is due and payable for each full 30 day period the debt remains unresolved. By law all payments are applied to interest first, principal second. 42 C.F.R.411.24(m) After receiving payment, Medicare will send a letter stating the lien has been reduced to zero and the case is closed. 31
Medicare Conditional Payments Post Final Demand Options • Appeal • Financial Hardship Waiver • Compromise • “Best Interest of the Program” Waiver 32
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