for your Casualty Program W W W . C H I C A G O L A N D R I S K F O - PowerPoint PPT Presentation

Developing Alternative & Strategic Approach to Medicare Compliance for your Casualty Program W W W . C H I C A G O L A N D R I S K F O R U M . O R G

Developing Alternative & Strategic Approach to Medicare Compliance for your Casualty Program Presented by: Presented by: Thomas S. Thornton, III Michael Chmielewski Carr Allison Corporate Risk & Insurance Manager 100 Vestavia Parkway Ace Hardware Corporation Birmingham, AL 35216 Chicago Illinois tthornton@carrallison.com mchmi@acehardware.com Phone: 630-472-4961 205.949.2936 2

ORGANIZATIONAL CONCERNS Medicare’s impact upon program from both an increased cost • and administrative claim handling perspective Lack of clear direction and/or application of strategic claim • resolution options relating to Medicare compliance by: – TPA (whose interest are they protecting) – Carrier/excess (Are they invested in the decision) – Defense/Plaintiff’s attorneys (Do they understand the full MSP Act) What is a “Medicare Set Aside? • 3 3

ORGANIZATIONAL GOALS • Achieve Claim Closure • Remain Compliant with the Medicare Act • Avoid Unnecessary Spend – Save money! 4 4

Problems Plaguing The Industry Industry confusion with regard to complying with the Medicare • Act for both liability and workers’ compensation matters. Lack clearly defined and strategic approach to resolving cases • Allowing Medicare to drive how we handle and – evaluate our cases. How we evaluate and handle our cases should drive – how we respond to Medicare. Who is directing and managing the strategic Medicare • compliance response to non-litigated and litigated claims 5 5

Where Should Compliance under Medicare Act Begin ? 6 6

Medicare Secondary Payer Act And Impact Upon Casualty Program Section 111 Reporting Identification and Timely Verification of Medicare Status Documenting and Timely & Addressing Appropriate Medicare’s Future Reimbursement Interest (MSA) of Liens (CPC) 7

Section 111 Reporting and Impact Upon Casualty Claim Programs! Potentially impacts all liability settlements where • consideration paid is in excess of $750.00 and the release was signed on or after January 1, 2017. Three questions to ask – Defense and Plaintiff’s Bar confusion – Impact with Workers’ Compensation Claims and • Settlements: Ongoing Responsibility for Medicals has been – assumed or assigned; Settlement of indemnity/vocational; – Closure of Ongoing Responsibility for Medicals under – state act 8 8

Medicare Secondary Payer Act And Impact Upon Casualty Program Identification and Timely Verification of Medicare Status Timely & Appropriate Reimbursement of Conditional Payment Claims 9 9

Protection/Reimbursement of Conditional Payment Claims Liability Claims • Do not have to know CMS lien to evaluate and settle – case Medicare’s lien does not arise until date release is signed • (Field 80 Date of TPOC Available strategies – $750.00 or less waiver • 25% Reimbursement option for claims valued between $750 • and $5,000 Assume vs Assign • Pro Se vs Represented – Workers’ Compensation Claims • Purpose of Section 111 reporting – Denied claims – Assume vs Assign • 10 10

Medicare Secondary Payer Act And Impact Upon Casualty Program Identification and Timely Verification of Medicare Status Addressing Medicare’s Future Interest 11

Medicare’s Future Interest and Impact Upon Claim Handling Statutory Obligation Only Creates potential • Conditional Payment Lien Recovery by Medicare (42 USC 1395y : “Has or Had Responsibility) Submission is voluntary because of Due Process • Concerns No appellate avenue – Medicare’s analysis when voluntarily applied is • unconstitutional Liability determined by medical conditions claimed and/ released or – Medical bills paid (strict liability) Lifetime expectation – Subjectivity, available defenses, and human element are not – considered Arguable Standard: • Where future accident related medical treatment is reasonably – anticipated, appropriate allocation from settlement amount to reflect avoiding unreasonable burden shifting to CMS (42 CFR 411.46 ) 12 12

Medicare’s Future Interest and Impact Upon Claim Handling Liability Cases: • Allocate $0.00 where evidence substantiates that claimed – accident related condition has resolved; (PRN, 90 Day Rule, Temporary nature of injury) Allocate appropriate amount from settlement proceeds to – reflect avoiding unreasonable burden shifting Workers’ Compensation Cases • Analysis based upon claim value and exposure: – Self Allocate vs Medicare Vendor Report based upon claim • value and CMS work review or otherwise established threshold Non-Submit vs Voluntary Submission of Report • Medical cost projection report vs. CMS mandated analysis of • MSA 13 13

Casualty Program + Medicare Compliance – Identify Internal Goals within own Program – Invest in understanding risk vs cost vs reward marrying Program Goals with Medicare compliance • Medical Cost Projection vs Traditional Allocation Report • Non-Submit vs Voluntary Submit – Identify partners to help implement and manage compliance • TPAs, carriers and Medicare vendor – Redefine the boxes which are checked by those managing your claims through Standard Operating Procedures with checks and balances 14 • 14

QUESTIONS? Presented by: Thomas S. Thornton, III Attorney Carr Allison tthornton@carrallison.com 205-949-2936 15