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Medicaid & Medicare Pract actice ce Tips Eisenberg, Gilchrist - PowerPoint PPT Presentation

Jan 02, 2024 •664 likes •947 views

Medicaid & Medicare Pract actice ce Tips Eisenberg, Gilchrist & Cutt Candace Gleed Damian Huntsman (801) 366-9100 www.egclegal.com Medicaid Insurance provided by the State of Utah Financial need / disability / low-income

  1. Medicaid & Medicare Pract actice ce Tips Eisenberg, Gilchrist & Cutt Candace Gleed Damian Huntsman (801) 366-9100 www.egclegal.com

  2. 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

  3. 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

  5. First Initial Medicare Letter

  6. Medicare Important 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

  7. 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

  8. 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

  9. 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.

  10. • 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

  11. CMS.gov Reporting Guidelines

  15. Medicare – Letter / Notice of Case

  19. MSPRP Features & Benefits

  25. Final Demand

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