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Medicare, Medicaid & Private Plans - Important Information about Healthcare Liens in Personal Injury Settlements

  
  
  

Medicare, Medicaid and Private Healthcare Liens- Important Information about Healthcare Liens in Personal Injury SettlementsUnder the laws of most states, when a personal injury claimant receives a settlement, he or she must use part of that settlement to pay back whoever paid for the medical care needed to treat his or her injury, whether it’s the government (i.e. Medicare or Medicaid), an employee health plan, or a private health insurance company. These healthcare “liens” or “reimbursement obligations” are now a part of almost all personal injury settlements. Claimants should take the time necessary to make sure they understand their healthcare benefits, obligations and rights. Doing so will ensure that healthcare provider’s interest are evaluated and resolved in the most efficient and favorable fashion as well as help provide for continued access to good care.

In this ebook, we provide a guide to healthcare obligations faced by claimants and attorneys when settling personal injury cases. We breakdown the process and timeline and detail what claimants and their attorneys can do to help expedite the resolution of these obligations. However, if all of this seems overwhelming, you can skip to the question, “What can be done to ensure the most favorable result?” within each section which explains how GRG can take over this obligation. Our qualifications are rather straightforward: Knowledge, Experience and Compliance.

Among the tips are:
What is a lien? What are the different types of healthcare providers?
 

Medicare
What is it and what are the rules?
What are the different types of Medicare programs?
Do all of these Medicare plans have liens?
What is my reimbursement obligation to Medicare in a liability settlement?
How long does it normally take to resolve a medical lien? Why does it take so long?
What can I do to speed up the process?
Can I challenge or appeal Medicare’s lien?
Does Medicare have to pay any of the attorney fees and costs associated with my settlement?
What happens if I ignore Medicare’s lien?
What, if anything, must I do to preserve my Medicare coverage after a settlement?
What can be done to ensure the most favorable result?
What are the requirements for a Medicare “Set Aside?”

Medicaid
What is it and what are the rules?
What does “needs-based” mean?
What are the different types of Medicaid programs?
Are the Medicaid lien rules the same in every state?
What happens if I ignore Medicaid’s lien?
How long does it normally take to resolve a Medicaid lien?
What can I do to speed up the process?
Can I challenge or appeal Medicaid’s lien?
Does Medicaid have to pay any of the attorney fees and costs associated with my settlement?
What can be done to ensure the most favorable result?
What can I do to protect my SSI and Medicaid benefits after the settlement?

Employee Health Coverage
What is it and what are the rules?
What is your obligation as a beneficiary of an employee health plan?
What can be done to ensure the most favorable result?

how can GRG help?

Considering Medicare's Future Interest

  
  
  

Ask the Lien Resolution ExpertsQuestion GRG: My client is demanding funds after settlement, but does not want to do an MSA. Is there any affirmative duty by the attorney to withhold disbursing settlement proceeds to client? Is there any exposure to the attorney? Settlement did not encompass money for future medicals. What are my obligations here to Medicare and my client?

Answer: What a timely question in light of Medicare beginning to provide more guidance on how to address future medicals in liability settlements (via the Advanced Notice of Proposed Rulemaking issued earlier this year).  We know that we have to do something to address future medical obligations, but the question is what to do? While it does not automatically mean to fund a Medicare Set Aside (MSA) in every single settlement, the issue does warrant some deeper analysis and documentation in the file, knowing that formal rules and regs are coming.

To your exact question, there is no affirmative duty on an attorney to withhold settlement proceeds against our client’s wishes. In fact, it is likely to be found ethically impermissible to do so (following Model Rule 1.15(d) regarding safekeeping property).  However, there is nothing to say that everyone of us should have something to evidence the fact that our clients fully understand the ramifications and repercussions of failing to properly consider Medicare’s future interest under the MSP Act. Having that conversation, and then the client’s signature evidencing that understanding is paramount.  To that end, here is an MSA Disclosure Form you may use to accomplish that goal.  This is one of the several form docs generated when a client uses our MSA Decision Engine, which allows clients to ask and answer the question “Is an MSA appropriate based on these case specific facts” simply and easily.  The MSA Decision Engine is the lowest cost of compliance going today on the MSA issue and should give you some peace of mind knowing that you have complied with all current statutory, regulatory and administrative guidance from Medicare as well as relevant case law.

 Learn more about GRG's MSA & MS

Medical Malpractice & Loss of Consortium Claims

  
  
  

Ask the Lien Resolution ExpertsQuestion GRG: I filed a medical malpractice case in California which included a claim for loss of consortium by the wife. Medicare paid for most of the care. The case settled without a specific allocation of the proceeds between the loss of consortium claim and the medical malpractice claim. Query: 1) Does Medicare have any lien rights on the loss of consortium claim; and 2) Is there a standard practice applicable to the allocation?

Answer: Medicare is not bound nor will they honor any allocation agreement between settling parties, however, they will honor a court ordered allocation that is based on the merits of the case. In any allocation hearing, Medicare MUST be put on notice of the hearing. Absent a court ordered allocation for loss of consortium, Medicare has recovery rights

The MSP Manual 50.4.4: Designation in Settlements states “the only situation in which Medicare recognizes allocations of liability payments to non-medical losses when payment is based on a court order on the merits of the case. If the court or other adjudicator of the merits specifically designate amounts that are for payment of pain and suffering or other amounts not related to medical services, Medicare will accept the court’s designation. Medicare does not recover portions of court awards that are designated as payment for losses other than medical services.”

Mark Your Calendars

  
  
  

We've got a busy rest of the year lined up and we're sure we will be seeing many of you at seminars, conferences and CLEs to finish up the year! Our lien resolution expert attorneys will be speaking at many events, including the Defense Research Institute (DRI) Annual Meeting, Delaware Trial Lawyers Association and several National Business Institute (NBI) seminars. Take a look at some of our speaking & exhibiting events coming up and as always, be sure to stop by our booth to say hi!

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Defense Research Institute (DRI) Annual Meeting - John Cattie Speaking on Medicare Set Asides
October 24th-28th
New Orleans, LA

 

 

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National Business Institute (NBI) Medicare Set Asides Seminar with John Cattie
October 25th
New Orleans, LA

 

 

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National Workers' Compensation & Disability (NWCD) Conference & Expo
November 7th - 8th
Las Vegas, NV

 


Consumer Attorneys of California (CAOC) Annual Convention
November 8th-11th
San Francisco, CA

 

how can GRG help?

Learn more about GRG's MSA & MS

Medicare's Subrogation Rights Against SSDI Benefits - Do they have them?

  
  
  

Ask the Lien Resolution ExpertsQuestion: I settled my client's third party tort claim in March 2010 and his workers' compensation claim in Oct. 2011. Medicare has not and will not be asked to pay anything for his accident related medical care given he is covered by workers compensation. However, after he settled his comp claim he filed for and began receiving SSDI benefits. Does Medicare have a subrogation right against his SSDI benefits?

Answer: The answer to your question, in short, is ‘no’, but let’s discuss how we get there.  In settling both the liability claim and the workers’ comp (WC) claim, I’m certain that you determined that, based on the case specific facts as applied to the current law and guidance, that a Medicare Set Aside (MSA) was not appropriate.  From your question, I would guess the reason why you arrived at that conclusion was that your client lacked the proper Medicare enrollment status to warrant an MSA.  By that, I mean to say that your client was not a current Medicare beneficiary at the time of either settlement and did not possess a “reasonable expectation” of Medicare enrollment within 30 months (based on CMS’ own definition of the term located in the April 2003 WCMSA Policy Memo at Q/A #2).  Since your client lacked the proper Medicare enrollment status, no MSA was needed.  Having said that, Medicare would not have a right of subrogation against your client’s SSDI benefits going forward under the Medicare Secondary Payer Act (42 U.S.C. Sec. 1395y(b)(2)).  Of course, you documented your file with the results of your MSA conclusions in case a CMS official asks questions later about how your client “considered and protected” its future interest when resolving the claims.

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Medicare Secondary Payer and “Future Medicals”: GRG Submits Comments to CMS

  
  
  

Over the past several weeks we've posted a series of Alerts from Garretson Resolution Group (“GRG”) on the subject of Medicare Secondary Payer (“MSP”) and future medicals in liability settlements.  On June 14, 2012, the Centers for Medicare & Medicaid Services (“CMS”) filed an Advance Notice of Proposed Rulemaking (“ANPRM”).  This document solicited comments on standardized options that CMS is considering implementing to enable “beneficiaries and their representatives” to “meet their obligations to protect Medicare’s interest” with respect to future medicals in liability settlements (including self-insurance).  The comment period has now ended, as of August 14, 2012.

We invite you to review our comments to CMS in response to the ANPRM. You can review our comments in their entirety here. 

Client Alert #1 - CMS Advanced Notice of Proposed Rulemaking: Medicare Secondary Payer & Future Medicals

Client Alert #2 - Medicare Secondary Payer and "Future Medicals": Analysis of Proposed Options 1 & 2

Client Alert #3 - Medicare Secondary Payer and "Future Medicals": Analysis of Proposed Options 3 & 4

We also invite you to take the MSA Decision Engine for a test drive so you can witness firsthand how this state of the art compliance tool will address your MSA questions simply, quickly and cost-effectively.
 
Comments to CMS
Our comments to the ANPRM begin by noting that CMS’s proposed rules must clearly articulate how the following three issues will work operationally:


1) When do future medicals need to be addressed under the MSP Act?
2) How much needs to be “set-aside” to satisfy that obligation?
3) What should occur after determining that amount? 

More specifically, we commented on how CMS can address those three issues in the Proposed Regulations in order to provide clarity. In our comments relative to when future medicals need to be addressed under the MSP Act, we noted that a threshold screening should be performed to determine whether the individual/beneficiary possesses the proper characteristics making them a candidate for an MSA.  Absent the right characteristics (which include proper Medicare enrollment status and a need for future Medicare covered injury-related care), an individual/beneficiary should be able to easily address the obligation by memorializing what factor is not present, eliminating them from the MSA requirement.

Next, we commented at length about the need to determine that a future medical allocation exists within the gross award.  Recognizing this has always been difficult under the current construct, we recommended that CMS adopt a standardized future medical allocation methodology under any Proposed Regulations which fully recognizes the inherent differences between workers’ compensation and liability matters.  Absent such standard allocation methodology, we noted that disbursements would be frozen and CMS regional offices would face gridlock.  In order to determine how to calculate the future medical allocation, we recommended CMS look to factors such as costs of procurement, out of pocket expenses, state statutory caps, loss of earning capacity and loss of household services.  Only by taking such factors into account would CMS be able to ensure stakeholders are provided uniformity and finality on the issue of future medicals.

Finally, we included comments on what should occur after determining the future medical allocation.  Fully understanding the scope and magnitude of the situation, we recommended that the allocation methodology be self-actuating, predictable and allow for finality.  Allowing individuals/beneficiaries access to logic/methodology “certified” by CMS in the area of future medical allocation would ensure compliance but bridge the resource constraints currently experienced by CMS.  With a scalable, objective process at their fingertips and with assurance from CMS that such allocation complies with the MSP provisions, individuals/beneficiaries would have the finality they need to be able to agree to settle a case knowing their future Medicare benefits are protected. 

To read our full comments, click here. 

You can also read the full notice from CMS regarding Medicare Secondary Payer obligations and future medical care here.

What to Expect from GRG?
Without doubt, the options and related processes ultimately implemented by CMS must allow for scale, efficiency, and practicality. Our comments asserted a collective voice for these key attributes based on the feedback you provided. Now come the next steps. 

CMS will review the comments it receives and move toward promulgating rules and regulations in this area.  THE TIME IS NOW to implement a formalized approach to MSA compliance inside your firm.  Are you asking the proper questions at case intake? Do you have a process you can rely upon to ensure compliance in this constantly changing area?  Please contact the GRG Medicare Set-Aside Team at (888) 556-7526 or lienresolution@garretsongroup.com to take the first step by asking for a demonstration of the MSA Decision Engine. 
 
GRG will continue to monitor all guidance from CMS in order to update our MSA decision-making methodology.  Whether you engage GRG for a traditional MSA Evaluation letter, or utilize our “self-service” MSA Decision Engine technology-based service, you can rest assured your case will comply with current statutes, regulations and case law. You can learn more about GRG’s MSA services, including our MSA Decision Engine, on our website.

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Medicare Secondary Payer and “Future Medicals”: An Analysis of Proposed Options 3 & 4

  
  
  

This GRG Client Alert is the third in a series of Alerts from Garretson Resolution Group (“GRG”) on the subject of Medicare Secondary Payer (“MSP”) and future medicals in liability settlements.

On June 14, 2012, the Centers for Medicare & Medicaid Services (“CMS”) filed an Advance Notice of Proposed Rulemaking (“ANPRM”).  This document solicits comments on standardized options that CMS is considering implementing to enable “beneficiaries and their representatives to “meet their obligations to protect Medicare’s interest” with respect to future medicals in liability settlements (including self-insurance). Comments will be accepted until August 14th at 5:00PM EDT. 

The purpose of this Client Alert is twofold: 1) to provide a deeper dive on the nuts and bolts of the ANPRM (specifically, Proposed Options 3 and 4); and 2) to talk about how GRG’s Medicare Set-Aside (“MSA”) Decision Engine provides GRG clients with the ready-built platform to ensure MSA compliance on files today as well as in the future - no matter what regulations CMS formally implements - so that you will feel zero effect on your business.  We ask you to forward your comments to us for submission to CMS about these options. We also invite you to take the MSA Decision Engine for a test drive so you can witness firsthand how this state of the art compliance tool will address your MSA questions simply, quickly and cost-effectively.
 
Proposed Option 3 – “The individual/beneficiary acquires/provides an attestation regarding the Date of Care Completion from his/her treating physician.


GRG Comments – Proposed Option 3 contemplates situations where the individual/beneficiary can obtain a certification letter from the treating physician indicating that there are no more future injury-related care needs to be incurred.  Such a letter could be obtained either pre-settlement or post-settlement.  GRG believes this is a workable solution pre-settlement, but may pose issues post-settlement unless CMS provides a clear standard for who is liable for future medicals. We envision scenarios whereby an individual/beneficiary may be nearing the Date of Care Completion at the time of mediation, but the parties desire to actually have the treating physician attestation in hand before reaching any final accord.

Proposed Option 4 – “The individual/beneficiary submits proposed Medicare Set Aside Arrangement (MSA) amounts for CMS’ review and obtains approval.”


GRG Comments – GRG believes a part of the overall solution should include some ability for the individual/beneficiary to submit a proposed MSA to CMS for review and approval.  Having said that, CMS would need to have the resources in place in order to provide a timely review of the MSA proposal.  A better solution would be that CMS allow an individual/beneficiary’s MSA allocation calculation to be self-actuating to avoid placing undue stress on the agency and to allow for finality at the time of settlement.  By instituting a process which allows for MSA allocation calculations to be self-actuating, individuals/beneficiaries would be able to address this issue with the same certainty as if CMS reviewed/approved the MSA allocation without placing undue stress on agency resources. In order to put this process in place, CMS may look to entities who have the experience and resources to accommodate the complexity and volume of MSA allocations which would be calculated under any final rules instituted.  In the absence of a full resource solution from CMS, a self-actuating solution could stand on its own merits as beneficiaries and those the produce the work product (plaintiffs’ counsel and MSP compliance entities) are already bound by the integrity of their work product.


You can read the full notice from CMS regarding Medicare Secondary Payer obligations and future medical care here.

 What to Expect from GRG?
Without doubt, the options and related processes ultimately implemented by CMS must allow for scale, efficiency, and practicality. Our goal is to assert a collective voice for these key attributes. Please contact the GRG Medicare Set-Aside Team at (888) 556-7526 or lienresolution@garretsongroup.com to provide thoughts or feedback.
 
GRG will continue to monitor all guidance from CMS in order to update our MSA decision-making methodology.  Whether you engage GRG for a traditional MSA Evaluation letter, or utilize our “self-service” MSA Decision Engine technology-based service, you can rest assured your case will comply with current statutes, regulations and case law. You can learn more about GRG’s MSA services, including our MSA Decision Engine, on our website.
 
If you have not already done so, please contact us to discuss how we can establish a formalized approach to MSA compliance within your firm.

We appreciate your feedback on Proposed Options 3 and 4 as we prepare our comments to CMS.  Further, we will continue to keep you up to date as additional information becomes available.  

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​Medicare Secondary Payer and "Future Medicals": Analysis of Proposed Options 1 & 2

  
  
  

This GRG Client Alert is the second in a series of Alerts over the next three weeks from Garretson Resolution Group (“GRG”) on the subject of Medicare Secondary Payer (“MSP”) and future medicals in liability settlements.

On June 14, 2012, the Centers for Medicare & Medicaid Services (“CMS”) filed an Advance Notice of Proposed Rulemaking (“ANPRM”).  This ANPRM solicits comments on standardized options that CMS is considering implementing to enable “beneficiaries and their representatives to meet their obligations to protect Medicare’s interest with respect to future medicals in liability settlements (including self-insurance).”

The purpose of this Client Alert post is twofold: 1) to provide a deeper dive on the nuts and bolts of the ANPRM (specifically, Options 1 and 2); and 2) to talk about how GRG’s Medicare Set-Aside (“MSA”) Decision Engine provides GRG clients with the ready-built platform to ensure MSA compliance on files today as well as in the future – no matter what regulations CMS formally implements – so that you will feel zero effect on your business.  We ask you to forward your comments to us for submission to CMS about these options.  We also invite you to take the MSA Decision Engine for a test drive so you can witness firsthand how this state of the art compliance tool will address your MSA questions simply,quickly, and cost-effectively.

Proposed Option 1 – “The individual/beneficiary pays for all related future medical care until his/her settlement is exhausted and documents it accordingly.”


• GRG Comments – Proposed Option 1 contemplates a situation where the individual/beneficiary has been adequately compensated for his/her anticipated future medical expenses within the gross settlement amount while also being adequately compensated for his/her other damages sustained (past medicals, wage loss, non-economic damages, etc.).  However, having the individual/beneficiary pay for all related future medical care until his/her settlement is exhausted and documents it accordingly, in and of itself, appears to overreach the current statutory obligation of the MSP Act (42 U.S.C. Sec. 1395y(b)(2)).  However, if the language read “The individual/beneficiary does not bill or authorize his/her medical providers to bill Medicare for any related future medical care until the portion of his/her settlement allocated to future medicals or expenses is exhausted and documents it accordingly”, then Option 1 would fully embrace the meaning and spirit of the MSP Act, whose intent is to ensure the Medicare Trust Fund remain the secondary payer post-settlement.

Proposed Option 2 – “Medicare would not pursue ‘future medicals’ if the individual/beneficiary’s case fits all of the conditions under either of the following headings:

a) The amount of liability insurance (including self-insurance) ‘settlement’ is a defined amount or less and the following criteria are met:


a. The accident, incident, illness or injury occurred one year or more before the date of ‘settlement’;
b. The underlying claim did not involve a chronic illness/condition or major trauma;
c. The beneficiary does not receive additional ‘settlements’; and
d. There is no corresponding workers’ compensation or no-fault insurance claim.”

• GRG Comments – GRG supports a safe harbor option such as the one posed here, and believes the defined amount tied to this option is critical to this option having an operational impact.  The gross settlement amount defined by CMS here must take into account the large volume of liability claims resolved annually.  A defined amount set too low would not take this volume into account and would create operational inefficiencies in settlement programs nationwide. 

b) “The amount of the liability insurance (including self-insurance) ‘settlement’ is a defined amount or less and all of the following criteria are met:


a. The individual is not a beneficiary as of the date of ‘settlement’;
b. The individual does not expect to become a beneficiary within 30 months of the date of ‘settlement’;
c. The underlying claim did not involve a chronic illness/condition or major trauma;
d. The beneficiary does not receive additional ‘settlements’; and
e. There is no corresponding workers’ compensation or no-fault insurance claim”

• GRG Comments – A safe harbor provision for those individuals who lack the proper Medicare enrollment status (either currently enrolled or “reasonable expectation” of enrollment within 30 months of settlement) would create settlement efficiencies. However, we recommend CMS clarify the phrase ‘expect to become a Medicare beneficiary within 30 months of the date of settlement’.   In conjunction with this Option 2(b), we recommend CMS apply the standard of “reasonable expectation” as is currently in use in workers’ compensation context when determining workload review thresholds.

You can read the full notice from CMS regarding Medicare Secondary Payer obligations and future medical care here.

What can clients expect from GRG?
Without doubt, the options and related processes ultimately implemented by CMS must allow for scale, efficiency, and practicality. Our goal is to assert a collective voice for these key attributes. Please contact the GRG Medicare Set-Aside Team at (888) 556-7526 or lienresolution@garretsongroup.com to provide thoughts or feedback.

GRG will continue to monitor all guidance from CMS in order to update our MSA decision-making methodology.  Whether you engage GRG for a traditional MSA evaluation letter, or utilize our “self-service” MSA Decision Engine technology-based service, you can rest assured your case will comply with current statutes, regulations and case law.  You can learn more about GRG’s MSA services, including our MSA Decision Engine on our website. 

If you have not already done so, please contact us to discuss how we can establish a formalized approach to MSA compliance within your firm.

We appreciate your feedback on the Proposed Option 1 and Option 2 as we prepare our comments to CMS.  Further, we will continue to keep you up to date as additional information becomes available.  

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CMS Advanced Notice of Proposed Rulemaking: Medicare Secondary Payer & Future Medicals

  
  
  

This GRG Client Alert is the first in a series of Alerts over the next three weeks from Garretson Resolution Group (“GRG”) on the subject of Medicare Secondary Payer (“MSP”) and future medicals in liability settlements.  CMS ANPRM Ruling, MSA, MSP

On June 14, 2012, the Centers for Medicare & Medicaid Services (“CMS”) filed an Advance Notice of Proposed Rulemaking (“ANPRM”).  The ANPRM solicits comments on standardized options that CMS is considering implementing to enable “beneficiaries and their representatives to meet their obligations to protect Medicare’s interest with respect to future medicals in liability settlements (including self-insurance)”. Comments will be accepted until August 14th at 5:00PM EDT. 

The purpose of this Client Alert is twofold: 1) to provide a deeper dive on the nuts and bolts of the ANPRM (specifically, the CMS Proposed General Rule and Proposed Definitions); and 2) to talk about how GRG’s Medicare Set-Aside (“MSA”) Decision Engine provides GRG clients with the ready-built platform to ensure MSA compliance on files today as well as in the future - no matter what regulations CMS formally implements - so that you will feel zero effect on your business.  We ask you to forward your comments to us for submission to CMS about the Proposed General Rule and Proposed Definitions.  We also invite you to take the MSA Decision Engine for a test drive so you can witness firsthand how this state of the art compliance tool will address your MSA questions simply, quickly, and cost-effectively.
 
Background

In the ANPRM, CMS acknowledges that practitioners in the liability settlement context have been seeking definitive guidance relative to future medicals.  CMS further acknowledges that while such guidance and a corresponding process has been available in the workers’ compensation context, to date no such guidance or process has been established for meeting MSP obligations with respect to future medicals in liability settlements.  As such, the ANPRM specifically requests comment on “whether and how Medicare should implement a similar process in liability insurance situations as well as comment on… proposed options” outlined in the notice.
 
CMS Proposed General Rule

“If an individual or Medicare beneficiary obtains a ‘settlement’ and has received, reasonably anticipates receiving, or should have reasonably anticipated receiving Medicare covered and otherwise reimbursable items and services after the date of ‘settlement’, he or she is required to satisfy Medicare’s interest with respect to ‘future medicals’ related to his or her ‘settlement’ using any one of the following options outlined later in this ANPRM.”

GRG Comments:The general rule that is ultimately enacted must provide settling parties with greater certainty when resolving claims and allow individuals/beneficiaries to make more informed decisions at the time of settlement.  This general rule makes sense, so long as the options available to satisfy Medicare’s future interest clearly define which type of cases are within the scope of the rule and which are not (i.e. making certain cases “out of scope” by definition without further analysis).  Further, for the types of settlements that are within the scope, the options for satisfying Medicare’s interest must be highly scalable and cost-effective to apply.

Proposed Definitions

“Several proposed definitions have been developed for use in conjunction with the options Medicare is considering.  All definitions have been considered and/or developed for the purposes of this document.  We request comment on the definitions of ‘chronic illness/condition’, ‘physical trauma’, and ‘major trauma’, specifically, whether they are accurate and usable in terms of the presumption that future medical care will be required.

Chronic Illness/Condition

An illness/condition that persists over a long period of time. 

Date of Care Completion

The date the individual/beneficiary completed treatment related to his or her ‘settlement.’ 

Future Medical Care (‘future medicals’)

Medicare covered and otherwise reimbursable items and services that the individual/beneficiary received after the Date of ‘Settlement.’ 

Physical Trauma

An injury (as a wound) to living tissue caused by an extrinsic agent. 

Major Trauma

A serious injury to two or more Injury Severity Score (ISS) body regions or an ISS greater than 15. 

GRG Comments – In general, the definitions appear appropriate because they set a standard which is both readily understood and applied for each based on current industry standards.  We note the following:

    • Using the strict AMA definition of ‘Chronic Illness/Condition’ in the MSP context is not understandable or workable, and will not result in settlement efficiencies based on defining the chronic illness or condition purely on a term certain without further explanation.  For example, an acute injury, such as a femur fracture, may take 8-12 months for the bone remodeling to occur.  Based on the AMA definition of ‘chronic illness/condition’, such an injury would be classified as a chronic illness or condition.  The natural healing process should not count against a Medicare beneficiary in establishing the severity of the injury for purposes of determining how to address Medicare’s future interest under the MSP Act.

    • The term ‘Physical Trauma’ should have different nomenclature in order to better align with other definitions.  (Possibly renamed as ‘Acute Trauma’ as CMS listed in proposed definition of ‘Chronic Illness/Condition.’)   

    • Applying the ISS scale to the definition of ‘Major Trauma’ may be helpful, but is not as helpful as establishing a presumptive rule concerning the requirement of future medical care in a ‘settlement’ as the Abbreviated Injury Scale (“AIS”), which is more specific. 

    • Changing ‘Major Trauma’ to the term ‘Catastrophic Trauma/Injury’ would be more consistent with industry practice, based on our experience.

You can read the full notice from CMS regarding Medicare Secondary Payer obligations and future medical care here.

What can clients expect from GRG?

Without doubt, the options and related processes ultimately implemented by CMS must allow for scale, efficiency, and practicality. Our goal is to assert a collective voice for these key attributes. Please contact John Cattie at (704) 559-4300 or jcattie@garretsongroup.com to provide thoughts or feedback.
 
GRG will continue to monitor all guidance from CMS in order to update our MSA decision-making methodology.  Whether you engage GRG for a traditional MSA evaluation letter, or utilize our “self-service” MSA Decision Engine technology-based service, you can rest assured your case will comply with current statutes, regulations and case law.  You can learn more about GRG’s MSA services, including our MSA Decision Engine on our website. 

If you have not already done so, please contact our MSA Team to discuss how we can establish a formalized approach to MSA compliance within your firm.

We appreciate your feedback on the CMS Proposed General Rule and Proposed Definitions as we prepare our comments to CMS.  Further, we will continue to keep you up to date as additional information becomes available.   

GRG at AAJ Convention - Thanks for stopping by!

  
  
  

GRG American Association for Justice

"Medicare Mary" Skinner speaks with a visitor at the GRG booth.

Thank you to everyone who stopped by our booth at AAJ this past weekend! We enjoyed speaking with each of you about our services and how GRG can help ease your frustration with healthcare compliance obligations. We have lots of business cards in our drawing for the free Kindle Fire. Be sure to check back as we will be announcing the winner soon!

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The Lien Resolution Experts. Garretson Resolution Group assists the settlement community by evaluating the settling parties' affirmative obligation and satisfying health care providers’ interests in personal injury, wrongful death, workers compensation, and mass tort settlements. We provide the following Healthcare Lien Resolution Services: Medicare Lien Resolution, Medicaid Lien Resolution, Private Health Care Lien Resolution, ERISA Lien Resolution, Hospital Lien Resolution, Provider Lien Resolution, VA Lien Resolution, TRICARE Lien Resolution, Indian Health Services Lien Resolution

The Medicare Set Aside (MSA) Experts. In addition to satisfying Medicare's past interests -- reimbursement for conditional payments -- GRG expertly evaluates and resolves Medicare's future interests in workers' compensation and third party liability cases by establishing Medicare Set Asides when appropriate. Backed by years of experience in working with Medicare, our innovative MSA Decision Engine and dedicated team of attorneys, analysts and RNs make GRG the industry's most trusted authority.

The MSP Consulting and Mandatory Insurer Reporting Experts. The Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) took effect in 2010, significantly changing resolution obligations and adding more penalties for non-compliance to the MSP Statute. Companies across the country look to GRG to ensure Medicare Secondary Payer (MSP) compliance and serve as their MMSEA Mandatory Insurer Reporting Agent.

The Complex Settlement Administration Experts. Parties are confronted with complex master settlement agreements that include complicated disclosure guidelines, stringent participation requirements, strict timelines, and constantly changing ethics rules. In the midst of that, attorneys must ensure that healthcare liens are resolved and bankruptcy and probate requirements are satisfied. GRG engineers and executes comprehensive settlement programs built upon our expertise in: Special Master and Settlement Allocation Services, Claims Administration, Medical Record Review, Fund Administration, Claimant Education, National Probate Coordination, National Bankruptcy Coordination and Healthcare Lien Resolution.

For more information please visit GRG's Homepage.