copyright 2014. iso claims partners retains sole ownership and copyright rights to this...
TRANSCRIPT
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Copyright 2014. ISO Claims Partners retains sole ownership and copyright rights to this presentation. Any use or reproduction of this presentation without prior written consent and approval of ISO Claims Partners is prohibited.
Medicare Hot TopicsPrepared by: Mark Popolizio,
Jessica Smythe
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• SMART Act - new laws enacted and CMS implementation proposalso Section 111o Conditional paymentso Other MSP areas
• Independent CMS proposalso Future medicals question
• Congressional activityoWCMSA
• Judicial decisionso Several areas, most notably Medicare Advantage
• Let’s take a look by MSP area ….
MSP Compliance – Where is the Action?
Section 111 Hot Topics
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1. Section 111 penalty provisions being formulated• SMART Act softens the Section 111 penalty provision• CMS released ANPRM in December – comments closed 2/10/14• Waiting for CMS to know release its exact proposals (including
“good faith” safe harbors• Issues/considerations
2. New low dollar TPOC threshold for liability claims• SMART Act calls for a yearly low dollar threshold for liability
claims• CMS must set this figure for each the next year by every
November 15• Feb 2014 --- CMS announced that the new low dollar liability
TPOC will be $1,000 starting 10/1/14 (this was to supposed to reset to $300 – but will now be $1,000 come 10/1)
• No change in the WC TPOC threshold
Section 111 – Hot Topics
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3. SSN/HICN• SMART Act calls for CMS to eliminate the required use of
SSN/HICNs for 111 purposes• Technically due this July – but CMS afforded liberal time
extensions• Case law consideration: Taylor v. General Electric
4. ICD 10 Transition (delayed to 10/1/15)
Section 111 – Hot Topics
Conditional Payments – Hot Topics
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1. New Expedited Conditional Payment Process• SMART Act -- Parties can get “final” CP figure prior to settlement• Sept 2013 – CMS releases Interim Final Rule (IFR) to implement• Issues created --
– SMART Act timetables vs. CMS’ IFR– CMS proposes that full functionality of the portal will not be ready until Jan
2016
• Issues/considerations/status
2. Challenging CP Claims (Appeals)• SMART Act -- formal appeal rights extended to primary payers• December 2013: CMS releases Proposed Rule • CMS proposing that payers have access to the existing five level
administrative review process (which included access to federal court)
• Issues/considerations/status
Conditional Payments – Hot Topics
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3. New low dollar CP threshold for physical trauma liability claims • SMART Act calls for low dollar CP threshold for physical
trauma liability claims• Feb 28, 2014: CMS sets this figure at $1,000• Thus, physical trauma liability settlements of $1,000 or less
are exempt from CP consideration• Threshold to be reset each year (CMS must announce figure
by Nov. 15th each year)• Issues/considerations
Conditional Payments – Hot Topics
WCMSA – Hot Topics
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1. CMS Proposes to Expand its “Reconsideration” process• Current process• What is CMS proposing? How would it differ from current
state?• Comment period closed 3/31/14• Waiting now for CMS to hold a Town Hall call to discuss how it
will expand the process
2. WCRC Contractor • WCMSA Reference Guide• Consequence of WCRC’s approach since November• Claims impact• Recent developments• What does the future hold?
WCMSA Issues – Hot Topics
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3. HR 1982 (WCMSA Reform Bill)• Currently pending in Congress• Proposes several reforms to the WCMSA process including (in
general):– Settlements below $25k exempt for MSP– Streamlining review thresholds– Percentage calculation method for certain cases– Direct deposit option– Establish review timelines and appeals process– Greater recognition of state law– Limited liability for post-settlement administration
WCMSA Issues – Hot Topics
LMSA – Hot Topics
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1. CMS’ ANPRM – Waiting for Medicare’s Next Move• ANPRM released in June 2012 • CMS seeking to establish formal legal regulations governing
“future medicals” in liability settlements• Series of 7 options – when action would (and would not) be
necessary– When specific action would be necessary, CMS proposing
that the plaintiff could:• Use whole settlement for future meds• Propose a LMSA• Propose a specified percentage of his/her net proceeds
• Waiting for CMS to now release its NPRM– Was supposed to be released in September 2013– But nothing to date
• Issues/Considerations/Impact
LMSA Issues – Hot Topics
Medicare Advantage Plans
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1. MA Plans – The next compliance frontier?o Original Medicare vs. MA Planso Facts and Figures
2. Current issues :oDo MA plans have private cause of action rights?oDoes the MA Act preempt state anti-lien/subrogation laws?
• Case law considerations• Watch list cases
3. Practical claims considerations – How to deal with MA Plans?
Medicare Advantage Plans – Hot Topics
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Questions?
Mark Popolizio(786) 459-9117
Jessica Smythe(919) 437-8037
www.iso.com/claimspartners