A Practical Approach to MSP

1. A Practical Approach to MSP Charleston County Bar February 14, 2014

2. Overview • Medicare Insurance • Worker’s Compensation Insurance • Medicare Secondary Payer Regulations • Cost Projections • Affordable Care Act • Preparing for Settlement • Settlement Language • Roadblocks to Successful Settlements • Post Settlement Issues ProjectWorks

3. Who Am I? • Registered Nurse • Certified Nurse Life Care Planner • Medicare Specialist Certified Consultant • Legal Nurse Consultant • Certified Disability Management Specialist • Certified Case Manager • Certified Insurance Rehabilitation Specialist ProjectWorks

4. Experience • 15 years clinical and community health nursing • 15 years medical case management nursing • 15 years legal nurse consulting and life care planning • 5 years Medicare compliance ProjectWorks

5. Team • Jenny Glasgow • Medical Case Manager ProjectWorks • Shawn Davis • Paralegal Joye Law Firm ProjectWorks

6. Your Class • Ask/answer questions of me • Ask/answer questions of each other • Offer comments • Bring your own experiences to this seminar • A lot of information today ProjectWorks

7. Who are you? • How many represent plaintiff clients • How many represent carrier/defense • How many work only cases in SC • How many work cases outside SC ProjectWorks

8. Pop Quiz • Define and explain: • MSP LOR • SMART COB • CHIP MSPRC • ANPRM R&R • WCMSA LR • LMSA CMS • ACA HELP ProjectWorks

9. Scoring • If can answer less than 5, need to stay for full class • If can answer 5-10, can use texting while in class • If can answer 10-13, will be called upon to help teach • If can answer all 14, provide contact information ProjectWorks

10. Part 1 MEDICARE INSURANCE ProjectWorks

11. Medicare Insurance • Eligibility • Age • Disability • Certain medical conditions • Premiums • Part A • Part B • Part D • Medigap ProjectWorks

12. General Coverage • Hospital, with per occurrence and daily co-pays • Skilled nursing facility, with co-pays after 20 days • Home health, skilled services only • Medical office visits, with 80/20 co-pays • Physical & occupational therapy, with 80/20 co-pays • Durable medical equipment, with 80/20 co-pays • Diagnostics, with 80/20 co-pays • Counseling, with 65/35 co-pays ProjectWorks

13. Medications • Significant co-pays • Significant deductibles • Significant exclusions ProjectWorks

14. Fee Schedule • Medicare fee schedule • Some physicians not accepting Medicare rates • Billed rate, then adjustments on paid rate • 80% of Medicare rate ProjectWorks

15. Not covered • TNS unit and supplies • Bathroom equipment • Home attendant care • Transportation • Some wheelchair equipment • Dental services • Vision and hearing services and equipment • Podiatry visits ProjectWorks

16. Handout #1 • Chart on Medicare coverage ProjectWorks

17. Part 2 WORKERS COMPENSATION INSURANCE ProjectWorks

18. WC Insurance • Payment of all inpatient treatment • Payment of all outpatient treatment • Payment of prescription drugs • Payment of durable medical equipment ProjectWorks

19. WC • Payment of all required premiums • Employers buy insurance from WC carriers • Employers are self insured • State Accident Fund ProjectWorks

20. WC • No co-pays • No deductibles • No exclusions ProjectWorks

21. WC • Claim’s administration • Pays bills • Schedules appointments • Reports to CMS • Negotiates rates • Authorizes treatment • Case management ProjectWorks

22. WC • Each state has its own WC fee schedule • Differs from Medicare fee schedule • Differs from group health insurance fee schedule • SC WC fee schedule updates about every 5 years • Providers offer additional discounts to WC carriers ProjectWorks

23. WC • Medical mileage reimbursement • Transportation to/from medical appointments • Pays for out of pocket expenses ProjectWorks

24. Summary • Medicare covers whole body but has co-pays and deductibles • Workers Compensation has no co-pays and deductibles but covers injury related parts only ProjectWorks

25. Part 3 MEDICARE SECONDARY PAYER ProjectWorks

26. MSP • MSP regulations, 1980 • Medicare Secondary Payer • SMART Act, January 2013 • Strengthening Medicare and Repaying Taxpayers • ANPRM, October 2013 • Advanced Notice of Proposed Rule Making cms.gov ProjectWorks

27. MSP • Says Medicare is secondary to all other insurances and medical funding, including settlements • Group health insurance • VA benefits • Workers Compensation • Auto liability insurance • Any liability coverage • Settlements ProjectWorks

28. Secondary • …for past medical payments • …for current treatment • …for future medical care ProjectWorks

29. MSP • Who is impacted • Class 1: already a Medicare beneficiary • Class 2: going to be a Medicare beneficiary within 30 months ProjectWorks

30. MSP • CMS will do a pre-settlement review: • Already a Medicare beneficiary and settlement $25,000 or more (Class 1) • Going to be a Medicare beneficiary within 30 months and settlement $250,000 or more (Class 2) ProjectWorks

31. MSP • Post-settlement review for all cases • CMS very often wants more than MSA allocation • How to handle this • Who is responsible for additional monies • Settlement language ProjectWorks

32. MSP • Impacts Worker’s Compensation cases • Impacts Liability cases ProjectWorks

33. MSP • Affects all parties • Insurance carriers • Defense attorneys • Plaintiff attorneys • Claimants • Physicians and providers ProjectWorks

34. Handout #2 • 4 questions to ask each and every client ProjectWorks

35. Universal Precautions • Consider each case as being impacted until proven not to be • Categorize each case as: • Not impacted • Class 1 • Class 2 ProjectWorks

36. Do • Add 4 questions to intake sheet • Add 4 questions to settlement checklist • Be mindful of age and hitting the 62.5 mark ProjectWorks

37. Do • Continuously update records with information • Insurance coverage • Application to SSDI • Application to SSI • Medicaid eligibility • Medicare eligibility • Social Security Administration correspondence ProjectWorks

38. Do • Obtain copies of all insurance cards ProjectWorks

39. Do • Sign in-house medical authorization • Sign CMS authorization ProjectWorks

40. Do • Look at internal file management systems • Look at daily work flow • Look at computer management programs ProjectWorks

41. Do • Look at contract language • Do you need to add anything to clarify • Additional expenses for experts • Reporting requirements • Other case costs specific to MSP • Outsourcing to experts ProjectWorks

42. Do • Start educating client from day 1 on settlement impact of MSP ProjectWorks

43. Do • Plaintiff and defense work together to obtain all necessary reporting information for CMS ProjectWorks

44. Break • Questions • Comments • Discussion This was the easy stuff ProjectWorks

45. More MSP • Regulations require reasonable consideration for future medical treatment • Regulations require reasonable consideration for future prescriptions • Pay back of any/all conditional payments made ProjectWorks

46. Shawn Davis • Paralegal with Joye Law Firm • Conditional payments her “specialty” Contact: Joye Law Firm: 843.725.4279 sdavis@joyelawfirm.com ProjectWorks

47. Conditional Payments • Set up claim with Medicare Coordination of Benefits (COB) and provide a copy of letter to MSPRC. These are two different offices. • Include as attachments the signed Consent to Release and Proof of Representation forms (available on Medicare’s website). ProjectWorks

48. Rights and Responsibilities • Be sure the R&R letter includes the correct claim and/or policy number • Will also provide you with a Case ID Number ProjectWorks

49. Case ID Number • Case ID Number is the “key” to the claim • All treatment-related claims are filed under this Case ID Number • All correspondence to Medicare should reference this Case ID Number • Contact Medicare if receive correspondence with more than one Case ID Number to get all claims moved to the correct case • Make sure other cases are closed ProjectWorks

50. Requesting Conditional Lien • Notify Medicare of all treatment-related claims by provider, date of service, and total charge amount • Request specifically a “conditional lien amount” to avoid getting a final demand amount • Be sure to review all claims outlined in the conditional lien letter from Medicare to ensure related to injury • Send a Notice of Dispute to Medicare for any unrelated claims ProjectWorks