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NY Chapter - RIMSNY Chapter - RIMS

MMSEA Reporting MMSEA Reporting & MSP & MSP ComplianceCompliance

NY Chapter - RIMSNY Chapter - RIMS

MMSEA Reporting MMSEA Reporting & MSP & MSP ComplianceCompliance

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Medicare Compliance - Medicare Compliance - EvolutionEvolution

• Passed in 1980: 42 USC 1395y and 42 CFR 411 Passed in 1980: 42 USC 1395y and 42 CFR 411

• Legislative Intent: Medicare will always be a Legislative Intent: Medicare will always be a “Secondary Payer” if a primary payer exists“Secondary Payer” if a primary payer exists

• Primary Payers include: Workers’ Compensation, Primary Payers include: Workers’ Compensation, Liability, Auto No Fault, USL&H, Jones Act, and Group Liability, Auto No Fault, USL&H, Jones Act, and Group HealthHealth

• In July of 2001, CMS introduced the MSA Review and In July of 2001, CMS introduced the MSA Review and Approval process for certain WC settlementsApproval process for certain WC settlements

• In December of 2007, SCHIP Extension Act was In December of 2007, SCHIP Extension Act was passed into law and affects claims that involve passed into law and affects claims that involve payments, settlements, judgements, awards with payments, settlements, judgements, awards with Medicare beneficiariesMedicare beneficiaries

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Why the Mandatory Insurer Why the Mandatory Insurer Reporting?Reporting?

• Primary Purpose – Enforce MSP Compliance Primary Purpose – Enforce MSP Compliance RequirementsRequirements

• CBO Assessment – plans to collect $1.1 Billion in CBO Assessment – plans to collect $1.1 Billion in fines from “Primary Payers” for non-compliancefines from “Primary Payers” for non-compliance

CIVIL MONEY PENALTY FOR FAILURE TO REPORT:CIVIL MONEY PENALTY FOR FAILURE TO REPORT:

$1,000.00 per day per claim$1,000.00 per day per claim

• They intend to use the data to collect They intend to use the data to collect pastpast payments payments

• They intend to use the data to stop They intend to use the data to stop erroneouserroneous future future paymentspayments

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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

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Conditional Payments

• Requires that all Medicare “liens” are Requires that all Medicare “liens” are reimbursed in a timely mannerreimbursed in a timely manner

• If not paid by claimant/plaintiff in 60 days post-settlement If not paid by claimant/plaintiff in 60 days post-settlement become the responsibility of the primary payerbecome the responsibility of the primary payer

• US v. HarrisUS v. Harris• Medicare can recover double damages plus interest and Medicare can recover double damages plus interest and

attorney feesattorney fees• Projected Trends with Conditional Payments - in 2010, 2011 & Projected Trends with Conditional Payments - in 2010, 2011 &

forwardforward

• Requires that “adequate consideration” of Requires that “adequate consideration” of Medicare’s interest is shown in all Medicare’s interest is shown in all settlements involving a Medicare Eligible settlements involving a Medicare Eligible claimant/plaintiffclaimant/plaintiff

• Absent an allocation Medicare can recover the entire settlement Absent an allocation Medicare can recover the entire settlement amountamount

• CMS - Past Recovery & Future Protection CMS - Past Recovery & Future Protection

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Integrated Solution - StepsIntegrated Solution - Steps

MSP Compliance & SCHIP ReportingMSP Compliance & SCHIP Reporting

Step One: Step One: Identify - MQFIdentify - MQF

Step Two:Step Two: Satisfy – CPR & Satisfy – CPR & LNSLNS

Step Three:Step Three: Allocate Allocate

Step Four:Step Four: Report - MIR Report - MIR

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G&L Contact InformationG&L Contact Information

Duke T. Wolpert, MSI, SCLADuke T. Wolpert, MSI, SCLA

Vice President of Strategic ServicesVice President of Strategic Services

Gould & Lamb, LLCGould & Lamb, LLC

101 Riverfront Blvd., Suite 100101 Riverfront Blvd., Suite 100

Bradenton, FL 34205Bradenton, FL 34205

1-866-672-3453 Ext 10671-866-672-3453 Ext 1067duke.wolpert@gouldandlamb.com

www.gouldandlamb.com