Medicare Hot Topics
Prepared by: Mark Popolizio,
Jessica Smythe
Copyright 2014. ISO Claims Partners retains sole ownership and copyright rights to this presentation. Any use or
reproduction of this presentation without prior written consent and approval of ISO Claims Partners is prohibited.
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MSP Compliance – Where is the Action?
• SMART Act - new laws enacted and CMS implementation proposals
o Section 111
o Conditional payments
o Other MSP areas
• Independent CMS proposals
o Future medicals question
• Congressional activity
o WCMSA
• Judicial decisions
o Several areas, most notably Medicare Advantage
• Let’s take a look by MSP area ….
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Section 111 Hot Topics
Section 111 – Hot Topics
1. Section 111 penalty provisions being formulated
• SMART Act softens the Section 111 penalty provision
• CMS released ANPRM in December – comments closed 2/10/14
• Waiting for CMS to know release its exact proposals (including “good
faith” safe harbors
• Issues/considerations
2. New low dollar TPOC threshold for liability claims
• SMART Act calls for a yearly low dollar threshold for liability claims
• CMS must set this figure for each the next year by every November 15
• Feb 2014 --- CMS announced that the new low dollar liability TPOC
will be $1,000 starting 10/1/14 (this was to supposed to reset to $300
– but will now be $1,000 come 10/1)
• No change in the WC TPOC threshold
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Section 111 – Hot Topics
3. SSN/HICN
• SMART Act calls for CMS to eliminate the required use of SSN/HICNs
for 111 purposes
• Technically due this July – but CMS afforded liberal time extensions
• Case law consideration: Taylor v. General Electric
4. ICD 10 Transition (delayed to 10/1/15)
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Conditional Payments – Hot Topics
Conditional Payments – Hot Topics
1. New Expedited Conditional Payment Process
• SMART Act -- Parties can get “final” CP figure prior to settlement
• Sept 2013 – CMS releases Interim Final Rule (IFR) to implement
• Issues created -– SMART Act timetables vs. CMS’ IFR
– CMS proposes that full functionality of the portal will not be ready until Jan 2016
• Issues/considerations/status
2. Challenging CP Claims (Appeals)
• SMART Act -- formal appeal rights extended to primary payers
• December 2013: CMS releases Proposed Rule
• CMS proposing that payers have access to the existing five level
administrative review process (which included access to federal court)
• Issues/considerations/status
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Conditional Payments – Hot Topics
3. New low dollar CP threshold for physical trauma liability claims
• SMART Act calls for low dollar CP threshold for physical trauma
liability claims
• Feb 28, 2014: CMS sets this figure at $1,000
• Thus, physical trauma liability settlements of $1,000 or less are exempt
from CP consideration
• Threshold to be reset each year (CMS must announce figure by Nov.
15th each year)
• Issues/considerations
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WCMSA – Hot Topics
WCMSA Issues – Hot Topics
1. CMS Proposes to Expand its “Reconsideration” process
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Current process
What is CMS proposing? How would it differ from current state?
Comment period closed 3/31/14
Waiting now for CMS to hold a Town Hall call to discuss how it will
expand the process
2. WCRC Contractor
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WCMSA Reference Guide
Consequence of WCRC’s approach since November
Claims impact
Recent developments
What does the future hold?
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WCMSA Issues – Hot Topics
3. HR 1982 (WCMSA Reform Bill)
• Currently pending in Congress
• Proposes several reforms to the WCMSA process including (in general):
– Settlements below $25k exempt for MSP
– Streamlining review thresholds
– Percentage calculation method for certain cases
– Direct deposit option
– Establish review timelines and appeals process
– Greater recognition of state law
– Limited liability for post-settlement administration
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LMSA – Hot Topics
LMSA Issues – Hot Topics
1. CMS’ ANPRM – Waiting for Medicare’s Next Move
• ANPRM released in June 2012
• CMS seeking to establish formal legal regulations governing “future
medicals” in liability settlements
• Series of 7 options – when action would (and would not) be necessary
– When specific action would be necessary, CMS proposing that the
plaintiff could:
• Use whole settlement for future meds
• Propose a LMSA
• Propose a specified percentage of his/her net proceeds
• Waiting for CMS to now release its NPRM
– Was supposed to be released in September 2013
– But nothing to date
• Issues/Considerations/Impact
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Medicare Advantage Plans
Medicare Advantage Plans – Hot Topics
1. MA Plans – The next compliance frontier?
Original Medicare vs. MA Plans
o Facts and Figures
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2. Current issues :
o Do MA plans have private cause of action rights?
o Does the MA Act preempt state anti-lien/subrogation laws?
• Case law considerations
• Watch list cases
3.
Practical claims considerations – How to deal with MA Plans?
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Questions?
Mark Popolizio
(786) 459-9117
[email protected]
Jessica Smythe
(919) 437-8037
[email protected]
www.iso.com/claimspartners
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