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Briefing: Medical Affirmative Claims

Briefing: Medical Affirmative Claims. Date: 24 March 2010 Time: 1110 – 1200. Statutory Authority. Federal Medical Care Recovery Act, 42 USC 2651-2653 Against “third party” insurance belonging to negligent third party 10 USC 1095 Against the patient’s “first party” insurance

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Briefing: Medical Affirmative Claims

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  1. Briefing:Medical Affirmative Claims Date: 24 March 2010 Time:1110 – 1200

  2. Statutory Authority • Federal Medical Care Recovery Act, 42 USC 2651-2653 • Against “third party” insurance belonging to negligent third party • 10 USC 1095 • Against the patient’s “first party” insurance • Same statute that authorizes health insurance claims

  3. Army Regulations AR 27-20, Chapter 14 AR 40-400, Chapter 13

  4. Types of Affirmative Claims Medical Affirmative Claims (MAC) - All insurance recoveries EXCEPT health insurance Property Damage Recoveries Lost Wage Claims

  5. How Are MAC Claims Different? Unlike TPCP (health insurance claims): Can assert for medical care provided to soldiers Requires more proof/advocacy by legal offices and possible litigation Authority to collect resides with legal offices per OTSG/OTJAG MOU and Army Regulations Billing issues

  6. Types of MAC Claims Auto Accidents Workers Compensation Premises Liability Products Liability Assaults Medical Malpractice

  7. Auto Insurance State-specific: See http://www.auto-insurance-finder.com (for summary of insurance laws of 50 states) Liability Coverage UM Coverage (uninsurance & underinsurance) Medical Payments Coverage Personal Injury Protection

  8. Example – Kansas Law Required Coverage Liability - $25,000 per person/$50,000 per accident UM coverage (cannot stack with liability) - $25,000 per person/$50,000 per accident PIP coverage - $4,500 per person Hypothetical: What happens if our medical claim is $100,000?

  9. Workers Compensation Non-federal employer On-the-job injuries State-specific forms and filing requirements

  10. Premises Liability Homeowners Insurance Renters Insurance RCI Privatized On-Post Housing All have liability and most have minimal no-fault insurance

  11. Identifying Potential MAC Claims MP Blotters Serious Incident Reports Newspapers Local civilian police reports Line-of-Duty investigations TRICARE fiscal intermediaries

  12. MTF Support Identifying MAC Claims Screen ER logs Develop Injury Treatment Questionnaire with legal office and require completion by patients Refer all attorney and insurance requests for records/bills to supporting legal office AR 40-400, Chapter 13 – requires coordinated effort between UBO and servicing legal office Coordinate billing efforts

  13. Sample Questionnaire

  14. Where Does the Money Go?  MTF Care - $$$ to MTF TRICARE - $$$ to TRICARE Proportional Distribution if MTF care and TRICARE TSG/TJAG MOU (1991) – MTF funding of legal office MAC recovery slots TSG/OTJAG/TRICARE MOU (2009) – TRICARE reimburses MTF for percentage of MTF-funded legal office MAC recovery slots

  15. MAC Billing Issues Time intensive What rates to use?

  16. Settling Medical Claims Payment in full? Compromise? Waiver? Termination? Litigation? Decision may reside at DA or DOJ level

  17. Quiz • MVA in Kansas. • Our injured has MTF bill for $20,000 • Our injured also has TRICARE payout of $40,000 • Tortfeasor has insurance coverage of $25,000/$50,000 • Our injured has UM coverage of $100,000 • What insurance is potentially available? • What factors impact how much we recover? • Where does the $$$ go?

  18. Q&A Questions?

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