Medicaid & MedicarePractice Tips

Eisenberg, Gilchrist & CuttCandace Gleed

Damian Huntsman(801) 366-9100

www.egclegal.com

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

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

First Initial Medicare Letter

MedicareImportant 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

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

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

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.

• Open only one case with Medicare for each applicable claim.

• If a claim for Liability / UIM run consecutive two cases are required to be open

• 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

CMS.gov Reporting Guidelines

Medicare – Letter / Notice of Case

MSPRP Features & Benefits

Final Demand