Medicare, Medicaid and Private Health Insurer Liens in Personal - PowerPoint PPT Presentation

T HE CONDI T I ONAL PAYME NT PROCE SS OF ME DI CARE AND T HE NE W SMART ACT 24

Co o rdina tio n o f Be ne fits Co ntra c to r (COBC)  CMS ha s c o nso lida te d a ll a c tivitie s in suppo rt o f the c o lle c tio n, ma na g e me nt, a nd re po rting o f o the r insura nc e c o ve ra g e o f Me dic a re b e ne fic ia rie s unde r a sing le e ntity, the Co o rdina tio n o f Be ne fits Co ntra c to r (COBC).  T he COBC is b a sic a lly the info rma tio n g a the re r to c o o rdina te b e ne fits o f Me dic a re re c ipie nts 25

MSP Re c o ve ry Co ntra c to r  CMS c o ntra c te d with the MSP Re c o ve ry Co ntra c to r (MSPRC) in 2006 to c o nso lida te a ll func tio ns re la te d to MSP re c o ve ry. I n 2014 the c o ntra c to r na me wa s c ha ng e d to Be ne fits Co o rdina to r & Re c o ve ry Co ntra c to r (BCRC).  T he BCRC ma na g e s a ll MSP a fte r the COBC c o mple te s a re c o rd.  Onc e the file is tra nsfe rre d fro m the COBC to the BCRC, the c la ima nt will re c e ive a “rig hts a nd re spo nsib ilitie s” le tte r (RAR) sig ne d b y the BCRC. 26

Re po rting Re q uire me nt  42 USC 1395y(b )(8) a nd 42 C.F .R. Se c tio n 411.25  All se ttle me nts, judg me nts, a wa rds o r o the r pa yme nts re so lving me dic a l fo r a Me dic a re Be ne fic ia ry c la ima nt must b e re po rte d  Re po rte d b y Pa ye r—no t Cla ima nt o r Pla intiff  F a ilure to g ive time ly no tic e o f a se ttle me nt to Me dic a re re sults in a c ivil mo ne y pe na lty o f “$1000 fo r e a c h da y o f no nc o mplia nc e with re spe c t to e a c h c la ima nt.” 42 U.S.C. 1395y (b )(8)(E )(i) (But Se e Ac t ) SMART 27

Wha t T rig g e rs Re po rting ?  T he RRE must re po rt a T ota l Pa yme nt Oblig a tion to the POC) whic h g e ne ra lly re pre se nt a ‘ o ne - Cla ima nt (T time ’ o r ‘ lump sum’ pa yme nt o f a se ttle me nt, judg me nt, a wa rd , o r o the r pa yme nt inte nde d to re so lve o r pa rtia lly re so lve a c la im. T he RRE must a lso re po rt no -fa ult/ Me d Pa y/ PI P a nd wo rke rs’ c o mpe nsa tio n c la ims.  Ma nda tory re porting is re quire d whe n the T POC da te a nd se ttle me nt a mount a re a s follows:  Ove r $100,000 – On o r a fte r Oc to b e r 1, 2011  Ove r $50,000 – On o r a fte r April 1, 2012  Ove r $25,000 – On o r a fte r July 1, 2012  Ove r $5,000 – On o r a fte r Oc to b e r 1, 2012  Ove r $2,000 – On o r a fte r Oc to b e r 1, 2013  Ove r $300 – On o r a fte r Oc to b e r 1, 2014 28

Se c tio n 111 a nd Disc o ve ry  Se c tio n 111 re q uire d e xte nsive info rma tio n disc lo sure , inc luding a c lie nt’ s SSN fo r the de fe nda nt to re po rt the c la im  CMS ha s no t b e e n willing to a c c e pt le ss tha n c o mple te info rma tio n  I nfo rma tio n so ug ht is g e ne ra lly no t the type e xc ha ng e d, e spe c ia lly in simple se ttle me nts  Co urt c o mpe lle d disc lo sure o f SSN re a so na b le in lig ht o f de fe nda nt’ s re po rting re q uire me nts: C , Do c ke t No .: 8:08CV75,  Se ge r v. T ank Conne c tion, L L US Dist. L E XI S 49013, D.Ne b . (Apr. 22, 2010) ofano, 2010 Co nn. Supe r. L E XI S 1669  Hac kle y v. Gar (Sup.Ct. July 1, 2010) 29

Co nditio na l Pa yme nts  Me dic a re ha s the rig ht to re c o ve r a ny c o nditio na l pa yme nt ma de a g a inst the se ttle me nt pro c e e ds o f a Wo rke r’ s Co mpe nsa tio n o r third-pa rty lia b ility c a se .  So me time s re fe rre d to a s a “supe r lie n” b e c a use o f the b ro a d po we r CMS ha s  F ro m the da te o f inc ide nt to the da te o f se ttle me nt 30

Wha t a re Co nditio na l Pa yme nts?  Pa yme nts b y Me dic a re whe n a no the r pa ye r is re spo nsib le .  E xa mple s:  Whe re the c la m is de nie d b y the c a rrie r o r se lf-insure d;  T he c a rrie r o r se lf-insure d do e s no t pa y pro mptly;  T he pa tie nt e le c ts to pursue una utho rize d tre a tme nt;  T he c la ima nt fa ils to file a c la im o r fa ils to no tify CMS o f the e xiste nc e o f o the r insura nc e ;  T he re is a lo ng de la y b e twe e n the filing o f the c la im a nd the c o urt pro c e e ding . 31

T he Co nditio na l Pa yme nt Pro c e ss (b y T e le pho ne ) Co nt. #1 : Pho ne the Co o rd ina tio n o f Be ne fits  ST E P Co o rdina to r. (COBC) 1-800-999-1118. Be pre pa re d to g ive the m the fo llo wing info rma tio n.  T he c lie nt’ s/ b e ne fic ia ry’ s na me .  T he He a lth I nsura nc e Cla im Numb e r (HI CN). T ypic a lly this is the c lie nt’ s So c ia l Se c urity Numb e r, plus a n a lpha c ha ra c te r.  T he g e nde r a nd da te o f b irth.  T he c lie nt’ s/ b e ne fic ia ry’ s a ddre ss a nd pho ne numb e r.  T he da te o f the inc ide nt/ a c c ide nt.  A de sc riptio n o f the injury b y b o dy pa rt. I f po ssib le , the y wo uld pre fe r I CD-9 c o de s.  T he type o f c la im- fo r e xa mple , a lia b ility insura nc e c la im.  Yo ur a tto rne y a nd firm na me a lo ng with yo ur a ddre ss a nd pho ne 32 numb e r.

T he Co nditio na l Pa yme nt Pro c e ss (b y T e le pho ne ) Co nt.  ST P #2 : Pro o f o f Re pre se nta tio n to Me dic a re Se c o nda ry E Pa ye r (MSPRC) lo c a te d in Okla ho ma City: 1-866-677-7220 Use the ir PROOF OF RE PRE SE NT AT I ON fo rm.  Che c k the b o x fo r a tto rne y.  Pro vide the a tto rne y na me , yo ur re la tio nship a s a n a tto rne y, the firm na me a nd a ddre ss a nd pho ne numb e r.  F ill in the c lie nt’ s na me a nd HI CN a nd the da te o f the inc ide nt.  Ha ve this sig ne d b y the c lie nt a nd da te d.  F a x this to the m a t 405-869-3309.  ST P #3 : T he y will no w se nd yo u a RI GHT S AND E RE SPONSI BI L I T I E S L E T T E R. T his will b e a sta nda rd fo rm b ut with the pa rtic ula rs re g a rding yo ur c la im. Yo u sho uld the n pre pa re a tic kle r fo r 65 da ys la te r in o rde r to mo nito r the pro c e ss a s sho wn b e lo w. 33

T he Co nditio na l Pa yme nt Pro c e ss (b y T e le pho ne ) Co nt. P #4 : I n re spo nse to the RI GHT S AND  ST E RE SPONSI BL I T I E S L E T T E R, yo u ne e d to re spo nd a nd se nd the fo llo wing :  Se nd a c o py o f yo ur re ta ine r a g re e me nt. Be sure it is fully fille d o ut a nd sig ne d b y b o th the c lie nt a nd b y yo ur firm.  Pla c e o n the to p o f the re ta ine r a g re e me nt the c lie nt’ s na me a nd the HI CN numb e r.  Se nd the m the na me , a ddre ss a nd te le pho ne numb e r o f the insure r a nd a lso the a djuste r. 34

T he Co nditio na l Pa yme nt Pro c e ss (b y T e le pho ne ) Co nt.  #5 : 65 da ys fro m the da te o f the RI GHT S AND ST E P RE SPONSI BI L I T I E S L E T T E R, the y will a uto ma tic a lly se nd yo u a CONDI T I ONAL PAYME NT L E T T E R (CPL ). Ho we ve r, if it ha s no t b e e n re c e ive d b y this time , yo u ma y wa nt to c a ll a nd inq uire . (Do no t c a ll in le ss tha n 65 da ys; if yo u do , yo ur re q ue st will put yo u a t the e nd o f the line . E a c h c a ll is c o nside re d a ne w re q ue st a nd , a s suc h, the time re sta rts.) At this time , the y po st a ll c o nditio na l pa yme nts info rma tio n und e r the “MyMSP” ta b o f the www.MyMe dic a re .g o v we b site , whic h is upda te d we e kly. T hus, yo u c a n tra c k it the re a fte r whe ne ve r ne c e ssa ry. I t is a t this po int tha t the y will ha ve a lso se nt yo u a  CORRE SPONDE NCE COVE R SHE E T whic h inc lude s pre -printe d info rma tio n o n yo ur c a se a nd will ha ve b o xe s to c he c k. T his will fa c ilita te a ll ma tte rs with the m.  NOT E : I f the tre a ting pro vide r ha s tro ub le with re imb urse me nt b y Me dic a re , ha ve the m c he c k the b o x fo r a c o nditio na l pa yme nt. T his will fa c ilita te the ir g e tting pa id b y Me dic a re . 35

T he Co nditio na l Pa yme nt Pro c e ss (b y T e le pho ne ) Co nt.  P #6 : Re vie w the CPL a nd se nd b a c k a le tte r to BCRC if so me ST E pa yme nts a re no t re la te d to the injury. It will he lp if yo u ha ve pre vio usly se nt a de sc riptio n o f the injury a nd inc lude d the ICD9 c o de s. I f yo u o b je c t, this will trig g e r a no the r 65 da y wa it fo r a NEW  CONDI T I ONAL PAYME NT L E T T E R. Onc e a g a in, do no t c a ll in le ss tha n 65 da ys b ut the re a fte r, a c a ll will e sc a la te the re vie w.  P #7 : One se ttle me nt is re a c he d, se nd a le tte r to MSPRC with a ll ST E the pe rtine nt info rma tio n. Use the ir F INAL SE T T L E ME NT DE T AI L DOCUME NT .  T he da te o f se ttle me nt o r judg me nt.  T he a mo unt o f the se ttle me nt o r judg me nt.  An ite mize d sta te me nt o f the a tto rne y fe e s a nd c o sts.  Whe the r o r no t a ny PIP o r Me d-pa y wa s a pplic a b le .  I f the c a se ha s b e e n dro ppe d, o r lo st, se nd the m the do c ume nta tio n so tha t the y c a n c lo se the ir file . 36

T he Co nditio na l Pa yme nt Pro c e ss (b y T e le pho ne ) Co nt.  Me dic a re pa ys its pro po rtio na te sha re o f a tto rne y fe e s a nd c o sts a nd the y will ma ke tha t c a lc ula tio n. P #8 : T he y will no w se nd yo u a fina l de ma nd. I t will ha ve  ST E a n ite miza tio n o f the b ills the y pa id. Onc e a g a in, c a re fully c he c k to b e sure tha t the se a re a c c ide nt re la te d b ills. I f no t, yo u must file a le tte r c o nte sting tha t fa c t.  Yo u ha ve 60 da ys within whic h to pa y the ir de ma nd. Yo u ha ve to pa y the de ma nd e ve n if yo u a re c o nte sting it. Yo u pa y the de ma nd, a nd file the c o nte st. T he y will re imb urse yo u whe n yo u win. I f yo u fa il to pa y within 60 da ys, the y will c ha rg e inte re st a nd pe na ltie s. 37

Ne w Auto ma te d Numb e r (866- 677-7220) What you will ne e d:  Ca se I de ntific a tio n Numb e r (a s fo und o n the Rig hts a nd Re spo nsib ilitie s le tte r)  Da te o f L o ss  Be ne fic ia ry's Da te o f Birth  L a st fo ur dig its o f the SSN  F irst fo ur le tte rs o f b e ne fic ia ry's la st na me  Me dic a re Numb e r 38

I CD9 Co de s  Co nditio na l pa yme nts sho uld o nly b e ma de to tho se b ills re la te d to the injury  Circ le unre la te d b ills a nd pro vide b a c k-up do c ume nta tio n  CMS will de te rmine the a mo unt o we d; re spo nse must b e file d within 60 da ys  T he o ptio ns pe rmitte d in the a nswe r a re a s fo llo ws: 1. E ve rything c la ime d is o we d a nd a c he c k is disb urse d fo r the c la ime d a mo unt; 2. So me ite ms c la ime d a re o we d, while o the rs a re no t; 3. All c la ime d ite ms a re de nie d a nd the re will b e no c he c k e nc lo se d fo r re imb urse me nt. 39

E xa mple fo r Ha ndling a Co nditio na l Pa yme nt (Po rta l) Whe n yo u sig n up the c lie nt g e t a c o py o f the ir Me dic a re 1. c a rd, Me dic a id c a rd a nd he a lth insura nc e c a rds (prio r insura nc e a t time o f a c c ide nt? ). Go to www.c ms.g o v. Clic k o n “Me dic a re ”-the n “Atto rne y 2. Se rvic e s.” Use the we b site fo rms-e ve n if yo u ha ve to a tta c h 3. info rma tio n. Print o ut mo de l Pro o f o f Re pre se nta tio n & Co nse nt to 4. Re le a se F o rms-c lie nt sig ns. 40

Co nditio na l Pa yme nt E xa mple 5. Re po rt c a se (dire c tio ns in “Re po rting a Ca se ” in Atto rne y Se rvic e s’ ta b ). 6. Ma il pro o f o f re pre se nta tio n a nd c o nse nt to re le a se fo rms to BCRC (use Co rre spo nde nc e Co ve r She e t). 7. Go to www.myme dic a re .g o v a nd c re a te a n a c c o unt fo r c lie nt so yo u c a n a c c e ss c la im info rma tio n with c lie nt’ s pe rmissio n. 41

Co nditio na l Pa yme nt E xa mple 8. K e e p c he c king myme dic a re .g o v fo r c lie nt info rma tio n, o r c a ll a uto ma te d numb e r to c he c k sta tus o f c o nditio na l pa yme nts. 9. Re vie w fo r a ny no n-injury re la te d e xpe nse s o n c o nditio na l pa yme nt she e t. Pre pa re do c ume nta tio n to c o rre c t no n-injury re la te d e xpe nse s. 10. F ina l Se ttle me nt De ta il Do c ume nt to MSPRC- a tta c h unsig ne d se ttle me nt sta te me nt. 11. Wa it 4-6 we e ks o r mo re . 42

ic a , Hadde n v. Unite d State s of Ame r . 3d 291 (6 th Cir 661 F . 2011)  Sixth Circ uit fo und in fa vo r o f the g o ve rnme nt, ho lding tha t the MSP do e s no t pro vide fo r a ppo rtio nme nt a nd Me dic a re ’ s c la im fo r c o nditio na l pa yme nts do e s no t ne e d to b e e q uita b ly re duc e d b y the a mo unt re c o ve re d.  Me dic a re ’ s rig ht to re imb urse me nt is sta tuto ry, no t e q uita b le . As a re sult, the y do no t c o nside r fa c to rs tha t limite d the re c o ve ry, suc h a s insuffic ie nt insura nc e c o ve ra g e , c o mpa ra tive ne g lig e nc e , e tc .  Se e a lso : We inste in v. Se b e lius, 2013 WL 1187052 (E D PA, 2-13-2013). 43

F ar me r s Insur anc e v. F or ke y, 764 F . Supp. 2d 1205, U.S. Dist. Ct. D. NV, De c . 29, 2010  Me dic a re ma y se e k re imb urse me nt via dire c t a c tio n o r thro ug h sub ro g a tio n. Sub ro g a tio n is limite d to c e rta in c irc umsta nc e s-a nd b a sic a lly o nly whe re a n individua l o r e ntity is e ntitle d to pa yme nt fo r a n ite m o r se rvic e whic h Me dic a re pa id.  Mo st Me dic a re re imb urse me nt a c tio ns a re no t sub je c t to a ppo rtio nme nt unde r sta te sub ro g a tio n la ws b e c a use the y a re dire c tio n a c tio ns.  Whe n e xe rc ising the De pa rtme nt’ s rig ht o f dire c tio n a c tio n, a ppo rtio nme nt do e s no t a pply, a nd Me dic a re ’ s rig ht to re c o ve r is supe rio r to individua l c la ims a g a inst insura nc e . 44

Pro c ure me nt Co sts  Me dic a re re duc e s its re c o ve ry a uto ma tic a lly to ta ke into a c c o unt the c o st o f pro c uring the judg me nt o r se ttle me nt.  T he c o sts inc lude a tto rne y’ s fe e s, e xpe rt witne ss fe e s a nd c o urt c o sts. I n o rde r to pro pe rly c a lc ula te this re duc tio n, the c la ima nt’ s a tto rne y must pro vide a c o py o f the fe e a g re e me nt a lo ng with do c ume nta tio n o f c o sts inc urre d during litig a tio n. 42 C.F .R. 411.37. 45

Har o v. Se blius, 789 F . Supp. 1179 (U.S. Dis. Ct. AZ May 9, 2011)  T he Co urt fo und tha t de ma nding c o nditio na l pa yme nt re imb urse me nt within 60 da ys a g a inst b e ne fic ia rie s who we re disputing the c la im wa s irra tio na l a nd inc o nsiste nt with the sta tuto ry sc he me pro viding wa ive r a nd a ppe a l rig hts. 46

CONRADL ASKA v. GE NE RAL CASUAL T Y COMPANY OF WISCONSIN Appe a l No. 2010AP2410 COURT OF APPE AL S OF WISCONSIN, DIST RICT F OUR 2013 Wisc . App. L E XIS 234 Ma rc h 14, 2013, de c ide d  Ho spita l c a nno t b e fo rc e d to a c c e pt Me dic a re c o nditio na l pa yme nts.  A pro vide r ma y ho ld o ut fo r the ir full fe e a nd a sse rt a lie n unde r sta te la w a g a inst a ny insura nc e p ro c e e ds, o r a c c e pt a Me dic a re c o nditio na l pa yme nt a t the Me dic a re fe e sc he dule , typic a lly the lo we st ra te a c c e pte d.  I f the pro vide r do e s no t e le c t to b ill Me dic a re within a ye a r, the n it c a n o nly re c o ve r a g a inst insura nc e pro c e e ds a nd if no insura nc e pa yme nt is e ve r ma de o r the jury fa vo rs the de fe nda nts, the pro vide r will g e t pa id no thing .  I t is a g a mb le a nd the d e c isio n is the pro vide rs a lo ne to ma ke . T he Me dic a re b e ne fic ia ry ha s no sa y in the ma tte r. 47

Ha rdship  Afte r se ttle me nt, the pla intiff c a n a pply fo r a ha rdship wa ive r to furthe r re duc e o r e limina te the lie n. Me dic a re c a n issue a full o r pa rtia l wa ive r, o r de ny the wa ive r c o mple te ly. T he sta nda rd tha t is a dhe re d to is whe the r re c o ve ry wo uld b e a g a inst e q uity a nd g o o d c o nsc ie nc e . T o de te rmine this, the fo llo wing fa c to rs ma y b e c o nside re d:  T he de g re e to whic h the b e ne fic ia ry c o ntrib ute d to c a using the o ve rpa yme nt;  T he de g re e to whic h Me dic a re a nd/ o r its c o ntra c to rs c o ntrib ute d to c a using the o ve rpa yme nt; 48

Ha rdship (c o n’ d)  T he d e g re e to whic h re c o ve ry o r a djustme nt wo uld c a use undue ha rdship fo r the b e ne fic ia ry;  Whe the r the b e ne fic ia ry wo uld b e unjustly e nric he d b y a wa ive r o f a djustme nt o f re c o ve ry;  Whe the r the b e ne fic ia ry c ha ng e d the ir po sitio n to the ir ma te ria l de trime nt a s a re sult o f re c e iving the o ve rpa yme nt o r a s a re sult o f re lying o n e rro ne o us info rma tio n supplie d to the b e ne fic ia ry b y Me dic a re . 49

Me dic a re a nd Wro ng ful De a th Ca se s .3d 1330 (11 th Cir. 2010) A adle y v. Se be lius , 621 F  Br c hild's lo ss o f pa re nta l c o mpa nio nship c la im is a pro pe rty rig ht b e lo ng ing to the c hild , no t Me dic a re .  Be nson v. Se be lius, 2011 WL 1087254 (D.D.C. 2011), Pla intiff fa c to re d his mo the r’ s me dic a l c la ims into the se ttle me nt c a lc ula tio n. T he c o nditio na l pa yme nts we re re c o ve ra b le b y CMS. 50

Me dic a re Adva nta g e Pla ns (Pa rt C) a nd the MSPA  T hird Circ uit Ca se s –De c ide d June 28, 2012  In re Avandia Marke ting, Sale s Prac tic e s and Produc ts L iability . 3d 353 (3 rd Cir. 2012) the c o urt he ld tha t the itigation, 685 F L Me dic a re Se c o nda ry Pa ye r Ac t (“MSP”) pro vide s Me dic a re Adva nta g e Org a niza tio ns (“MAOs”) with a priva te c a use a c tio n to se e k re c o ve ry a g a inst a prima ry pa ye r (suc h a s a lia b ility insure r o r se lf-insure d de fe nd a nt in a pe rso na l injury ma tte r) in F e de ra l c o urt.  T he c o urt c o nc lude d tha t the pla in te xt o f the MSP is b ro a d a nd unre stric te d, a nd the re fo re , a llo ws a ny priva te pla intiff with sta nding , inc luding MAOs, to b ring a c a use o f a c tio n a g a inst prima ry pa ye rs. 51

Me dic a re Adva nta g e Pla ns (Pa rt C) a nd the MSPA  Pa rra v. Pa c ifiCa re o f Arizo na , No . 11-16069, ho lding tha t a priva te insure r o pe ra ting a s a Me dic a re Adva nta g e Org a niza tio n Pla n is no t pe rmitte d to b ring a n a c tio n in fe de ra l c o urt se e king re imb urse me nt fo r $136,630.90 fro m a to rt se ttle me nt se c ure d b y survivo rs o f the de c e a se d in a wro ng ful de a th a c tio n.  T he Co urt ho lds tha t the fe de ra l sta tute , 42 U.S.C. § 1395y(b )(3)(A), "wa s inte nde d to a llo w priva te pa rtie s to vindic a te wro ng s o c c a sio ne d b y the fa ilure o f prima ry pla ns to ma ke pa yme nts." T his sta tute do e s no t a utho rize a suit fo r re imb urse me nt a g a inst its insure d (o r survivo rs) fo r re imb urse me nt. 52

SMART Ac t Histo ry  K no wn a s the S tre ng the ning M e dic a re A nd R e pa ying a xpa ye rs (SMART ) Ac t T  One o f the c o -spo nso rs, Re p. T im Murphy (R-Pa .) indic a te d the b ill ste mme d fro m a c o nstitue nt who wa s in a c a r a c c ide nt a nd ha d to wa it ye a rs fo r a se ttle me nt o n me dic a l b ills c o ve re d b y Me dic a re ;  T he b ill's le a d De mo c ra tic spo nso r wa s Re p. Ro n K ind (D- Wis.)  SMART Ac t wa s sig ne d b y Pre side nt Ob a ma o n Ja nua ry 10, 2013 53

SMART Ac t Purpo se  T he SMART Ac t wa s pa sse d a s pa rt o f H.R. 1845 a nd a tta c he d o nto a Me dic a re I VI G Ac c e ss Bill;  I t re fo rms se ve ra l a spe c ts o f the c o nditio na l pa yme nt a nd MMSE A Se c tio n 111 pro c e sse s  Ame nds Se c tio n 1862(b )(2)(B) o f the So c ia l Se c urity Ac t (42 U.S.C. 1395y(b )(2)(B)) 54

SMART Ac t: Se c tio n 201  T itle d “ De te rminatio n Of Re imb urse me nt Amo unt T hro ug h ffic ie nc y. ” CMS We b site T o I mpro ve Pro g ram E  Whe re c o nd itio na l pa yme nts ha ve b e e n ma de , a c la ima nt o r “a pplic a b le pla n” ma y a t a ny time 120 da ys prio r to the se ttle me nt, judg me nt o r a wa rd no tify the Se c re ta ry o f the e xpe c te d da te a nd a mo unt.  T he Se c re ta ry must pro vide c o nditio na l pa yme nt info rma tio n thro ug h a we b site a nd upda te the info rma tio n no la te r tha n 15 da ys a fte r a pa yme nt is ma de . 55

T he We b site Re q uire me nts (a a ) T he info rma tio n sha ll b e a s c o mple te a s po ssib le a nd sha ll  inc lude pro vide r o r supplie r na me , dia g no sis c o de s (if a ny), da te s o f se rvic e , a nd c o nditio na l pa yme nt a mo unts.  (b b ) T he info rma tio n a c c ura te ly ide ntifie s tho se c la ims a nd pa yme nts tha t a re re la te d to a po te ntia l se ttle me nt, judg me nt, a wa rd , o r o the r pa yme nt to whic h the pro visio ns o f this sub se c tio n a pply. (c c ) T he we b site pro vide s a me tho d fo r the re c e ipt o f se c ure  e le c tro nic c o mmunic a tio ns with the individua l, re pre se nta tive , o r pla n invo lve d.  (dd ) T he we b site pro vide s tha t info rma tio n is tra nsmitte d fro m the we b site in a fo rm tha t inc lude s a n o ffic ia l time a nd da te tha t the info rma tio n is tra nsmitte d.  (e e ) T he we b site sha ll pe rmit the individua l, re pre se nta tive , o r pla n to do wnlo a d a sta te me nt o f re imb urse me nt a mo unts (in this c la use re fe rre d to a s a `sta te me nt o f re imb urse me nt a mo unt') o n pa yme nts fo r c la ims unde r this title re la ting to a po te ntia l se ttle me nt, judg me nt, a wa rd, o r o the r pa yme nt. 56

We b site Do wnlo a d: F ina l Co nditio na l Pa yme nt De ma nd  I f c e rta in c o nditio ns a re me t, the la st sta te me nt do wnlo a d e d fro m the we b site c a n b e c o nside re d the fina l de ma nd.  F ro m the da te o f no tic e , the Se c re ta ry ha s 65 da ys to re spo nd , o the rwise the c o nditio na l pa yme nt b e c o me s fina l.  T he Se c re ta ry ma y e xte nd fo r a n a dditio na l 30 da ys if the Se c re ta ry sho ws tha t the re wa s a fa ilure in the c la ims a nd pa yme nt po sting syste m a nd the fa ilure wa s justifie d due to e xc e ptio na l c irc umsta nc e s . 57

Re so lutio n o f Disc re pa nc ie s  I f the c la ima nt b e lie ve s the re is a disc re pa nc y o ve r the c o nditio na l pa yme nt a mo unt, the individua l (o r re pre se nta tive ) must pro vide do c ume nta tio n e xpla ining the disc re pa nc y a nd a pro p o sa l to re so lve suc h disc re pa nc y. T he Se c re ta ry must re spo nd/ re so lve the dispute within 11 b usine ss da ys  o r the pro po se d re so lutio n b y the c la ima nt/ a pplic a b le pla n will b e de e me d a c c e pte d.  I f ma de within the 11 da ys, the Se c re ta ry ma y re je c t the pro po sa l if it is de te rmine d tha t the re is no t a re a so na b le b a sis to inc lude o r re mo ve c la ims o n the sta te me nt o f re imb urse me nt.  Within the 11 da y pe rio d the Se c re ta ry must re spo nd in a time ly ma nne r b y a g re e ing to the pro po sa l to re so lve the disc re pa nc y o r b y pro viding do c ume nta tio n sho wing with g o o d c a use why the Se c re ta ry is no t a g re e ing to suc h pro po sa l a nd e sta b lishing a n a lte rna te disc re pa nc y re so lutio n.  T he re is no a dministra tive o r judic ia l re vie w o f the Se c re ta ry's de te rmina tio ns. 58

E ffe c tive Da te  T his pro c e ss will g o into e ffe c t 9 mo nths a fte r H.R. 1845 g o e s into e ffe c t – o r o n Oc to b e r 10, 2013(e ffe c tive da te o f H.R. 1845 is Ja nua ry 10, 2013).  T his se c tio n a lso pro vide s tha t the Se c re ta ry c re a te a n a ppe a ls pro c e ss fo r c o nditio na l pa yme nts. 59

Se c tio n 202-T hre sho lds 15 th  By No ve mb e r e a c h ye a r, the Se c re ta ry will ha ve to pub lish a thre sho ld whe re in re po rting a nd c o nditio na l pa yme nt re imb urse me nt will no t a pply.  T his will b e g in in the ye a r 2014. 60

Se c tio n 203- Re po rting Re q uire me nts  Ame nds Se c tio n 1862(b )(8) o f the So c ia l Se c urity Ac t (42 U.S.C. 1395y(b )(8)  Re mo ve s the ma nda to ry c ivil pe na lty o f $1000 a da y fo r no n-c o mplia nc e with the Se c tio n 111 re po rting re q uire me nts a nd inste a d pro vide s tha t fa ilure to re po rt `ma y b e sub je c t to a c ivil mo ne y pe na lty o f up to $1,000 fo r e a c h d a y o f no nc o mplia nc e with re spe c t to e a c h c la ima nt.'; a nd  T he Se c re ta ry is re q uire d to de ve lo p re g ula tio ns fo r ide ntific a tio n o f pra c tic e s fo r whic h sa nc tio ns will o r will no t b e impo se d.  T he re g ula tio ns sha ll inc lude no t impo sing sa nc tio ns fo r g o o d fa ith e ffo rts to ide ntify a b e ne fic ia ry 61

Se c tio n 204 – So c ia l Se c urity Numb e rs  Ame nds Se c tio n 1862(b )(8)(B) o f the So c ia l Se c urity Ac t (42 U.S.C. 1395y(b )(8)(B))  Re po rting re q uire me nts a re mo difie d so tha t a RRE will no lo ng e r b e re q uire d to re po rt SSNs a nd/ o r he a lth ide ntific a tio n c la im numb e rs g o ing fo rwa rd . 62

Se c tio n 205 – Sta tute o f L imita tio ns  Ame nds 1862(b )(2)(B)(iii) o f the So c ia l Se c urity Ac t (42 U.S.C. 1395y(b )(2)(B)(iii))  T he sta tute o f limita tio ns fo r c o nditio na l pa yme nt re c o ve ry is 3 ye a rs a fte r the re c e ipt o f no tic e o f a se ttle me nt, judg me nt, a wa rd o r o the r pa yme nt ma de . 63

CURRE NT ST AT E OF T HE SMART ACT  T he fina l rule will b e pub lishe d in 2014  I nte rim fina l rule e xte nds the time pe rio d fo r CMS to a ppro ve a se ttle me nt to a s lo ng a s 245 da ys.  I F R “ig no re s the 120-da y sta tuto ry time - fra me ” o n CMS re spo nding to a re q ue st fo r a ppro va l o f a se ttle me nt. 64

I NT E RI M F I NAL RUL E 9/ 20/ 2013  CMS I SSUE S RUL E S-OBT AI NI NG F I NAL CONDI T I ONAL PAYME NT S VI A WE B PORT AL  As dire c te d b y SMART Ac t-c o nfo rms e xisting We b Po rta l to c o mply  E ffe c tive 11/ 19/ 2013  Go to : www.fe de ra lre g iste r.g o v. Se a rc h fo r “me dic a re sma rt a c t”  Will a llo w a tto rne ys, who a re re g iste re d, to ha ve a c c e ss to c o nditio na l pa yme nt info rma tio n fo r a c a se , inc luding da te s o f se rvic e s, pro vide r na me s, I CD9 Co de s, pa yme nt a mo unts.  T o b e imple me nte d no la te r tha n 1/ 1/ 2016 65

T HE ME DI CARE SE CONDARY PAYE R ST AT UT E 66

Me dic a re Se t-Aside (MSA) Arra ng e me nts  Se c tio n 1862(b )(2)(A)(ii) o f the So c ia l Se c urity, Ac t [42 USC 1395 y(b )(2)], pre c lude s Me dic a re pa yme nt fo r se rvic e s to the e xte nt tha t pa yme nt ha s b e e n ma d e o r c a n re a so na b ly b e e xpe c te d to b e ma de pro mptly unde r lia b ility insura nc e .  Me dic a re ha s the rig ht to sc rutinize a ny se ttle me nt o f wo rke r’ s c o mpe nsa tio n c a se o r third-pa rty lia b ility c a se to d e te rmine if its rig ht must b e pro te c te d a g a inst a shift to Me dic a re o f a ny third pa rtie s’ lia b ility a s it re la te s to future me dic a l c a re .  Unle ss fund s a re se t a side tha t will me e t the pa rtic ipa nt’ s future me dic a l b ills, Me dic a re will no t a ssume lia b ility fo r future me dic a l tre a tme nt whe n a third pa rty is re spo nsib le . 67

Me dic a re Se t Aside  T he la w do e s no t re q uire the m; it’ s me re ly a de vic e to use to c o mply with the la w.  No de finitio n o f “MSA” is in the MSP, its re g ula tio ns o r o the r la w.  MSA is a n a llo c a tio n o f se ttle me nt pro c e e ds a mo ng the va rio us da ma g e c o mpo ne nts o f a se ttle d c la im. 68

Histo ry o f the MSA  Me mo issue d July, 2001 (kno wn a s the “Pa te l Me mo ”) fo rma lly intro duc e d the Me dic a re Se t Aside (MSA)a rra ng e me nt re g a rding wo rke rs’ c o mpe nsa tio n  (WC) se ttle me nts.  MSA b e c a me a n e ffe c tive me a ns to ma na g e e xpo sure unde r the MSP.  CMS e mb ra c e d MSAs a s the pre fe rre d me a ns o f c o mplying with the MSP a nd minimizing future c o nditio na l pa yme nts. 69

NE W CMS RE F E RE NCE GUI DE F OR WCMSA  I ssue d Ma rc h 29, 2013  CMS will re vie w a pro po se d WCMSA a mo unt whe n the fo llo wing wo rklo a d re vie w thre sho lds a re me t:  T he c la ima nt is a Me dic ar y a nd the to ta l e be ne fic iar se ttle me nt a mo unt is gr than $25,000.00 ; o r e ate r  T he c la ima nt ha s a re a so na b le e xpe c ta tio n o f Me dic a re e nro llme nt within 30 months of the se ttle me nt date and the a ntic ipa te d to ta l se ttle me nt a mo unt fo r future me dic a l e xpe nse s a nd d isa b ility/ lo st wa g e s o ve r the life o r dura tio n o f the se ttle me nt a g re e me nt is e xpe c te d to b e gr e ate r than $250,000.00 . 70

NE W CMS RE F E RE NCE GUI DE F OR WCMSA  A c la ima nt ha s a re a so na b le e xpe c ta tio n o f Me dic a re e nro llme nt within 30 mo nths if a ny o f the fo llo wing a pply:  T he c la ima nt ha s a pplie d fo r So c ia l Se c urity Disa b ility Be ne fits  T he c la ima nt ha s b e e n de nie d So c ia l Se c urity Disa b ility Be ne fits b ut a ntic ipa te s a ppe a ling tha t de c isio n  T he c la ima nt is in the pro c e ss o f a ppe a ling a nd/ o r re -filing fo r So c ia l Se c urity Disa b ility b e ne fits T he c la ima nt is 62 ye a rs a nd 6 mo nths o ld   T he c la ima nt ha s a n E nd Sta g e Re na l Dise a se (E SRD) c o nditio n b ut do e s no t ye t q ua lify fo r Me dic a re b a se d upo n E SRD. I f the thre sho ld is me t, a WCMSA c a n b e sub mitte d to CMS fo r a ppro va l.   T he se thre sho lds a re c re a te d b a se d o n CMS’ wo rklo a d, a nd a re no t inte nd e d to indic a te tha t c la ima nts ma y se ttle b e lo w the thre sho ld with impunity. Cla ima nts must still c o nside r Me dic a re ’ s 71

NE W CMS RE F E RE NCE GUI DE F OR WCMSA  T he g o a l o f e sta b lishing a WCMSA is to e stima te , a s a c c ura te ly a s po ssib le , the to ta l c o st tha t will b e inc urre d fo r a ll me dic a l e xpe nse s o the rwise re imb ursa b le b y Me dic a re fo r wo rk-re la te d c o nd itio ns during the c o urse o f the c la ima nt’ s life , a nd to se t a side suffic ie nt funds fro m the se ttle me nt, judg me nt, o r a wa rd to c o ve r tha t c o st. WCMSAs ma y b e funde d b y a lump sum o r ma y b e struc ture d, suc h tha t a fixe d a mo unt o f funds a re pro vide d e a c h ye a r fo r a fixe d numb e r o f ye a rs.  Onc e the CMS-a ppro ve d se t-a side a mo unt is e xha uste d a nd a c c ura te ly a c c o unte d fo r to CMS, Me dic a re will pa y prima ry fo r future Me dic a re -c o ve re d e xpe nse s re la te d to the WC injury tha t e xc e e d the a ppro ve d se t-a side a mo unt. 72

Whe n to Co nside r a n MSA  Do e s the se ttle me nt invo lve a me dic a l c la im?  I s it re a so na b ly like ly tha t the injure d pe rso n will ha ve o ng o ing o r future me dic a l e xpe nse s re la te d to the c la ime d injury?  Are the se me dic a l e xpe nse s o the rwise c o ve re d b y Me dic a re ?  I s the b e ne fic ia ry like ly to b e a Me dic a re b e ne fic ia ry whe n suc h me dic a l e xpe nse s a re inc urre d? 73

Arg ume nt fo r L MSA  Sta tute is pre tty c le a r: Me dic a re is pro hib ite d fro m ma king pa yme nt whe n “pa yme nt ha s b e e n ma de , o r c a n re a so na b ly b e e xpe c te d to b e ma de unde r a pla n o f insura nc e .”  Our Re g io na l Offic e ha s indic a te d tha t MSA’ s sho uld b e use d in to rt c a se s to pro te c t CMS’ s inte re sts, a nd the sa me c rite ria use d in Wo rke r’ s Co mpe nsa tio n c a se s sho uld b e a pplie d. I f the pa rtie s ma ke a g o o d fa ith e ffo rt to a llo c a te the L MSA a nd  CMS la te r re vie ws the file , the b urde n is o n CMS to pro ve the a llo c a tio n wa s unre a so na b le . Re c e nt Me mo s a nd re q ue st fo r rule s.  F a ilure to a d he re c o uld c a use the Me dic a re b e ne fic ia ry to b e  de nie d b e ne fits T he de fe nda nts a nd the ir insure rs mig ht b e fo rc e d to pa y fo r future c a re tha t wa s a lre a d y c o mpe nsa te d fo r a s a c o mpo ne nt o f the se ttle me nt. T he pla intiff’ s a tto rne y is fa c e d with the po ssib ility o f a CMS re c o ve ry a c tio n a g a inst his fe e fro m the se ttle me nt. Atto rne ys o n b o th side s ma y fa c e ma lpra c tic e a c tio ns.  CMS re ta ins a re tro spe c tive re vie w to d e te rmine if its rig hts we re pro te c te d. 74

Arg ume nt Ag a inst L MSA  42 C.F.R. Se c tio ns 411.46 a nd 411.47 e xpre ssly pro vide a ma nne r b y whic h Me dic a re must a djust its b e ne fits, sho uld a n a llo c a tio n fo r future me dic a l e xpe nse s b e pro vide d in a wo rke rs’ c o mpe nsa tio n se ttle me nt; no suc h re g ula tio n fo r lia b ility c a se s.  CMS me mo in July, 2001 indic a ting MSAs wo uld no w b e re c o mme nde d in c e rta in insta nc e s o f c a se se ttle me nt, the me mo me ntio ne d o nly wo rke rs’ c o mpe nsa tio n c la ims. T he re wa s no la ng ua g e , pro c e sse s, o r pro c e dure s tha t a pplie d to lia b ility c la ims.  CMS is re fusing to re vie w mo st L MSAs. T he re a re c a se s whe re the se ttle me nt is no t e no ug h to c o ve r the  a llo c a tio n.  Wo rke rs’ c o mpe nsa tio n do e s no t invo lve po lic y limits.  I n lia b ility, the fo ur e le me nts o f ne g lig e nc e must b e a na lyze d (duty o we d , d uty b re a c he d , injury a nd pro xima te c a use ). Afte r tha t a na lysis, c o nc e pts suc h a s c o mpa ra tive o r c o ntrib uto ry ne g lig e nc e must b e ta ke n into c o nside ra tio n. Cle a rly, wo rke rs’ c o mpe nsa tio n is a n e a sie r c o nc e pt to c o mpre he nd tha n de te rmining ne g lig e nc e in a lia b ility a c c ide nt.  Se ttle me nt sho uld b e e njo ye d b y pla intiff; no t g ive n to CMS if no t 75 ne c e ssa ry.

CMS Guida nc e  4/ 22/ 03 Me mo in WCMSA:  T he fa c ts o f the c a se de mo nstra te tha t the injure d individua l is b e ing c o mpe nsa te d fo r pa st me dic a l e xpe nse s o nly.  T he re is no e vide nc e tha t the individua l is a tte mpting to ma ximize the o the r a spe c ts o f the se ttle me nt to Me dic a re 's de trime nt.  T he individua l’ s tre a ting physic ia ns c o nc lude (in writing ) tha t to a re a so na b le de g re e o f me dic a l c e rta inty the individua l will no lo ng e r re q uire a ny Me dic a re c o ve re d tre a tme nts. 76

Sa lly Sta lc up Me mo – 5/ 25/ 11  Sta lc up is the MSP Re g io na l Co o rdina to r-Da lla s, T e xa s (pe rta ins to AR, OK , T X, NM, L A).  “T he L a w re q uire s tha t the Me dic a re T rust F und s b e pro te c te d fro m pa yme nt fo r future se rvic e s whe the r it’ s a Wo rke r’ s Co mpe nsa tio n o r lia b ility c a se . T he re is no distinc tio n in the la w.”  T he re is no fo rma l pro c e ss fo r re vie w o f lia b ility c a se s.  Atto rne ys must de c ide b a se d upo n the fa c ts o f the ir c a se whe the r the T rust F und must b e pro te c te d. 77

Sa lly Sta lc up Me mo – 5/ 25/ 11  “T he fa c t tha t a se ttle me nt/ judg me nt/ a wa rd do e s no t spe c ify pa yme nt fo r future me dic a l se rvic e s do e s no t me a n tha t the y a re no t funde d.”  “T he fa c t tha t the a g re e me nt de sig na te s the e ntire a mo unt fo r pa in a nd suffe ring do e s no t me a n tha t future me dic a ls a re no t funde d.”  “Se t-a side is o ur me tho d o f c ho ic e a nd the a g e nc y fe e ls it pro vide s the b e st pro te c tio n fo r the pro g ra m a nd Me dic a re b e ne fic ia ry.” 78

Cha rlo tte Be nso n Guida nc e Me mo – 9/ 30/ 11  Be nso n is the Ac ting Dire c to r o f the F ina nc ia l Se rvic e s Gro up o f the Offic e o f F ina nc ia l Ma na g e me nt in Ba ltimo re , Ma ryla nd  Whe re the b e ne fic ia ry’ s tre a ting physic ia n c e rtifie s in writing tha t tre a tme nt fo r the a lle g e d injury re la te d to the lia b ility “se ttle me nt” ha s b e e n c o mp le te d a s o f the da te o f the “se ttle me nt,” a nd future me dic a l se rvic e s fo r injury will no t b e re q uire d, Me dic a re c o nside rs its inte re st, with re spe c t to future me dic a ls fo r tha t pa rtic ula r “se ttle me nt” sa tisfie d.  Whe n the re is suc h a c e rtific a tio n, the re is no ne e d fo r the b e ne fic ia ry to sub mit the c e rtific a tio n o r a pro p o se d L MSA fo r re vie w. CMS will no t pro vide the se ttling pa rtie s with c o nfirma tio n tha t Me dic a re ’ s inte re st with re sp e c t to future me dic a ls fo r tha t “se ttle me nt” ha s b e e n sa tisfie d.  T he b e ne fic ia ry a nd/ o r the ir re pre se nta tive a re e nc o ura g e d to ma inta in the physic ia n’ s c e rtific a tio n. 79

Me dic a re Se c o nda ry Pa ye r a nd ‘ F uture Me dic a ls’ Pro po se d Rule Ma king  On Ma y 3 o f 2012, CMS sub mitte d to the Offic e o f Ma na g e me nt a nd Budg e t a dva nc e d no tic e o f pro po se d rule ma king (ANPRM) e ntitle d "Me dic a re Se c o nda ry Pa ye r a nd 'F uture Me dic a ls' (CMS-6047- ANPRM).  So lic its c o mme nt o n o ptio ns to “c la rify ho w b e ne fic ia rie s c a n me e t the ir o b lig a tio ns to pro te c t Me dic a re 's inte re st with re spe c t to Me dic a re Se c o nda ry Pa ye r (MSP) c la ims invo lving a uto mo b ile a nd lia b ility insura nc e (inc luding se lf-insura nc e ), no - fa ult insura nc e , a nd wo rke rs' c o mpe nsa tio n whe n future me dic a l c a re is c la ime d o r the se ttle me nt, judg me nt, a wa rd , o r o the r pa yme nt re le a se s (o r ha s the e ffe c t o f re le a sing ) c la ims fo r future me dic a l c a re ." 80

Pro po se d Rule Ma king  T he CMS pro po se d g e ne ra l rule sta te s if a n “individua l o r Me dic a re b e ne fic ia ry” a ntic ipa te s re c e iving Me dic a re c o ve re d se rvic e s a fte r the da te o f the se ttle me nt, the n suc h pe rso n is re q uire d to sa tisfy Me dic a re ’ s inte re st with re spe c t to “future me dic a ls” using a ny o ne o f se ve ra l o ptio ns.  Optio n 1: T he Me dic a re b e ne fic ia ry pa ys fo r a ll future injury re la te d e xpe nse s o ut o f the se ttle me nt pro c e e ds until e xha uste d.  Optio n 2: No MSA is re q uire d if individua l is no t e xpe c te d to b e c o me a Me dic a re b e ne fic ia ry within 30 mo nths o f the se ttle me nt a nd the injury is no t “c hro nic ” a s de fine d a nd the se ttle me nt a mo unt is b e lo w a c e rta in a mo unt. Co mme nts we re so lic ite d o n wha t the thre sho ld a mo unt sho uld b e . T his wo uld b e simila r to the pro c e dure e mplo ye d in wo rke rs c o mpe nsa tio n c a se s.  Optio n 3. No MSA is re q uire d if the tre a ting physic ia n c e rtifie s the re a re no future injury re la te d e xpe nse s to b e inc urre d.  Optio n 4. A pro po se d MSA is sub mitte d to CMS fo r a ppro va l.  Optio n 5. T he Me dic a re b e ne fic ia ry pa rtic ipa te s in o ne o f the CMS re c o ve ry o ptio ns. T his o ptio n to c o ve r the sma lle r se ttle me nts.  Optio n 6. T he Me dic a re b e ne fic ia ry ma ke s a n upfro nt pa yme nt.  Optio n 7. T he individua l re c e ive s a c o mpro mise o r wa ive r fro m CMS a t the time o f the se ttle me nt. 81

Pro po se d Rule Ma king  T he pub lic c o mme nt pe rio d e nde d o n Aug ust 14, 2012  CMS initia te d the MSA rule ma king o n the ir o wn; no funding b y Co ng re ss  T his issue ha s ta ke n a b a c k-se a t to the SMART Ac t imple me nta tio n re q uire me nts. 82

Allo c a tio ns  Me dic a re is no t b o und b y the pa rtie s’ a llo c a tio n o f se ttle me nt funds  T he c o urt c a n de te rmine whe the r future me dic a l e xpe nse s a re like ly a nd the a mo unt o f the a llo c a tio n ne c e ssa ry fo r a MSA. Se e , Big R T owing v. Be noit , No . 6:2010c v00538 (W.D. L a 2010); 2011 WL 43219; F ’s Vie w , 2009 WL 6326944 inke v. Hunte r (D.Minn.); Sc he xnayde r v. Sc ottsdale , No . 6:2009c v01390, (W.D. L a ); 2011 WL 3273547 83

AL L OCAT I ON DE T E RMI NAT I ON  Co mpre he nsive Me dic a l Re c o rds Re vie w Pe rfo rme d b y MSCC (Me dic a re Se t-Aside Ce rtifie d Co nsulta nt)  Me dic a l Re c o rds (L a st 2 ye a rs): ide ntify missing me dic a l re c o rds  Suppo rting Me dic a l Re c o rds (L a st 2 ye a rs) i.e . T he ra py Se rvic e s, F CE , IME  Pha rma c y Summa ry (L a st 2 ye a rs)  Se ttle me nt (Pro po se d) Do c ume nts 84

In Re : Oil Spill by the Oil Rig “De e pwate r Hor izon” in the Gulf of Me xic o, on Apr il 20, 2010. T his Doc ume nt Re late s T o: No. 12- 968, Plaisanc e , e t al. v. BP E xplor ation & Pr oduc tion Inc ., e t al. and All Ac tions. MDL 2179 SE CT ION J UNIT E D ST AT E S DIST RICT COURT F OR T HE E AST E RN DIST RICT OF L OUISIANA XIS 4595 2013 U.S. Dist. L E  T he c o urt a c kno wle dg e d no t o nly the re imb urse me nt rig hts fo r re la te d me dic a l e xpe nse s a lre a dy inc urre d , b ut a lso q uo te d the F e de ra l Re g iste r so lic ita tio n la st summe r a s a utho rity suppo rting Me dic a re ’ s a sse rtio n o f a n inte re st in future me dic a l c a re .  T he mo st inte re sting se c tio n o f the o rde r c o nta ine d the sta te me nts a b o ut the ne g o tia tio n with CMS to e nsure tha t c la ss me mb e rs wo uld no t b e witho ut c o ve ra g e . 85

Smith v. Ma rine T e rmina ls of Arka nsa s, .D. AR, Aug . 9, 2011 2011 WL 3489806, U.S. E  Curre ntly e lig ib le Me dic a re pla intiff c a n se ttle b a se d o n third-pa rty a sse ssme nt o f future me dic a l e xpe nse s to a vo id litig a tio n a nd e nc o ura g e se ttle me nt to a vo id c o st a nd time re la te d to litig a tio n.  L itig a tio n wo uld ha ve se t fo rwa rd d e te rmina tio n o f, a mo ng o the r thing s, future me dic a l e xpe nse s. 86

Co urt invo lve me nt in I ssue s o f E q uita b le Allo c a tio n  t , 2013 Co nn.Supe r. L E XIS 245 (file d F e b rua ry 5, 2013) Ste r r e tt v. Kle ba r F e b rua ry 5, 2013, the Co urt, g ra nte d the se ttling pa rtie s’ mo tio n to  de te rmine tha t the pa rtie s ha ve re a so na b ly c o nside re d Me dic a re ’ s inte re sts a s re q uire d b y the Me dic a re Se c o nda ry Pa ye r (“MSP”) Ac t. T he pa rtie s ha d c o nc lude d tha t the y ha d re a so na b ly c o nside re d  Me dic a re ’ s future inte re st a nd tha t a lia b ility Me dic a re Se t-a side Arra ng e me nt (“L MSA”) wa s no t ne e de d a s pa rt o f se ttling the lia b ility c la im.  T he Co urt, a fte r re vie wing the e vide nc e pre se nte d, a g re e d tha t the pa rtie s ha d re a so na b ly c o nside re d Me dic a re ’ s future inte re st in c o nc lude d tha t no se ttle me nt pro c e e ds ha d b e e n “a llo c a te d” fo r future me dic a l e xpe nse s o the rwise c o ve re d b y Me dic a re within the g ro ss a wa rd. 87

F r ank v. Gate way Insur anc e Company, 2012 WL 868872, U.S. Dist. Ct., . 13, 2012 W.D. L A, Mar  Co urt o rde rs tha t de spite Me dic a re no t pa rtic ipa ting in a llo c a tio n o f future me dic a l, c o nditio na l pa yme nts a re o rde re d to b e pa id, future e xpe nse s will b e se t in inte re st-b e a ring a c c o unt a nd b a se d o n third-pa rty e stima te o f future e xpe nse s; o nc e inte re st-b e a ring a c c o unt is de ple te d b y Me dic a id c ha rg e s the n Me dic a re must pa y e ve n if re la te d to suit. 88

Siple r v. T r ans Am T r uc king, Inc ., US Distr ic t Cour t – Ne w Je r se y  Pla intiff invo lve d in PI c a se a nd re c e ive s Me dic a re  Co urt c o nc lude s tha t no Me dic a re a llo c a tio n is ne c e ssa ry.  T he se ttle me nt in this c a se did no t a rise in the wo rke r's c o mpe nsa tio n c o nte xt a nd it do e s no t indic a te a pa rtic ula r a mo unt to c o mpe nsa te Mr. Siple r fo r future me dic a l e xpe nse s a rising o ut o f the a c c ide nt.  T o rt c a se s invo lve no n-e c o no mic da ma g e s a nd no t de te rmine d b y a spe c ific fo rmula  T o re q uire pe rso na l injury se ttle me nts to spe c ific a lly a ppo rtio n future me dic a l e xpe nse s wo uld pro ve b urde nso me to the se ttle me nt pro c e ss a nd , in turn, disc o ura g e pe rso na l injury se ttle me nts. 89

Bruton v. Ca rniva l Corpora tion, 2012 WL , Ma y 2, 2012 1627729, US Dist. Ct. S. Dist. F L  Afte r re a c hing se ttle me nt a g re e me nt with g e ne ra l te rm tha t pla intiff must re le a se d e fe nd a nt fro m future lia b ility fro m Me dic a re c la ims, pla intiff strike s pro visio n fro m re le a se o f lia b ility tha t re q uire s pla intiff to se t up a se p a ra te a c c o unt to ho ld se t-a side a mo unt. De fe nda nt a rg ue s tha t “c o uld ” ma ke the m lia b le to Me dic a re fo r no t pro te c ting Me dic a re ’ s inte re st.  Co urt ho ld s tha t a c c o unt is no t re q uire d, a g re e me nt d o e s no t spe c ific a lly re q uire it, a nd de fe nda nt is suffic ie ntly pro te c te d de spite the fa c t tha t Me dic a re ha s no t g ive n suffic ie nt indic a tio n o f wha t pro te c ts the ir inte re st. Pla intiff’ s mo tio n to c o mpe l g ra nte d , a nd d e fe nd a nt re q uire d to pa y se ttle me nt a mo unt. 90

atio n , E ar ly v. Car nival Co r po r No. 12- 20478- CIV- Goodman y 7, 2013 ) (S.D. F la. F e br uar  T he se ttling pa rtie s a ske d the Co urt to de te rmine whe the r a lia b ility Me dic a re Se t-a side Arra ng e me nt (“L MSA”) wa s re q uire d a s pa rt o f se ttling the c la im.  T he Co urt c o nc lude d , a fte r re vie wing the e vide nc e , tha t the pa rtie s, in fa c t, did no t ha ve a se ttle me nt a g re e me nt a s the y did no t a g re e to e ve ry e sse ntia l te rm. 91

T ype s o f Arra ng e me nts  Se lf-Administe re d  Custo dial Ac c o unts  Spe c ial Ne e ds T rust  Po o le d T rust 92

Administra tio n  Distrib utio ns fro m the MSA ma y o nly b e ma de fo r me dic a l e xpe nse s tha t wo uld b e c o ve re d b y Me dic a re .  E a c h MSA must ha ve re a so na b le inve stme nt po lic y rule s a nd pro vide a c c o unting s.  T he a c c o unting s must b e ma de o n a n a nnua l b a sis to the Be ne fits Co ntra c to r re spo nsib le fo r mo nito ring the c a se . v. Showboat Atlantic City , 2011 N.J. Supe r. L E XI S 96,  Hinsinge r (Ja nua ry 21, 2011), a llo we d a tto rne y fe e s to b e pa id fro m the MSA. 93

Se lf-Administra tio n  Must c o mple te a nnua l a tte sta tio n, inte re st re po rte d, e lig ib le / c o ve re d ite ms, pa yme nt re c o rds, re la te d to MSA  Mino r Ca se s (Rx o r Ortho tic s o nly)  Unde rsta nding Me dic a re a llo wa b le ite ms 94

Pro fe ssio na l-Administra tio n  Allo ws fo r a lic e nse d , insure d a nd b o nde d insura nc e pro fe ssio na l to a dministe r the funds simila r to a wo rke rs’ c o mpe nsa tio n o r g ro up he a lth pla n  Administra to r is a c usto dia n o f a n a c c o unt, tha t is e sta b lishe d o n b e ha lf o f the c la ima nt  Co mple tio n o f the a nnua l a tte sta tio n file d with CMS 95

F unding  L ump sum  Struc ture d Se ttle me nts 96

Struc turing a n MSA  Pa ye r re c e ive s o ut-o f-po c ke t disc o unt b y purc ha sing a n a nnuity to fund to ta l a mo unt  I f funds a re e xha uste d b e fo re ye a r-e nd, Me dic a re c o ve rs funding 97

De a th  Onc e CMS de te rmine s tha t the c la ims ha ve b e e n pa id, a ny a mo unts re ma ining in the MSA ma y b e distrib ute d pursua nt to sta te la w. 98

Ve te ra n’ s Administra tio n  U.S. De pt. o f Ve te rans Affairs v Bo re si , No . SC 92541 (Mo . 2013); 2013 MO L e xis 25 (le xis.c o m), 2013 MO L e xis 25 (L e xis Adva nc e ) (April 30, 2013); a llo ws the VA to inte rve ne in a wo rke rs c o mp c a se to re c o ve r the ir me dic a l tre a tme nt c o sts fro m the injury.  T he c o urt c o nc lude d tha t fe de ra l la w wa s c o ntro lling a nd tha t 38 U.S.C. § 1729 a llo we d a n une q uivo c a l rig ht to inte rve ne in a ny a c tio n b ro ug ht a ve te ra n c o ve re d unde r a wo rke r’ s c o mpe nsa tio n la w o r pla n. T he Supre ma c y Cla use trumpe d a ny sta te c o mp la w. T he Misso uri c o mp la w ha d no pro visio n fo r inte rve ntio n in the se c irc umsta nc e s, a nd the c ivil rule s fo r inte rve ntio n unde r Rule 52.12 did no t a pply. 99

ME DI CAI D L I E NS: MORE COMPL I CAT I ON 100