How to Achieve Medicare Secondary Payer Compliance

How to Achieve Medicare Secondary Payer Compliance

Take Control of Your Insurance Settlements With A Brand New Resource From LexisNexis!

There are many people who don’t understand that the Centers for Medicare and Medicaid Services’ (“CMS”) approval process of a Medicare set-aside arrangement (“MSA”) is voluntary and carries an inherent cost. In fact, many of the decisions that need to be made in a settlement negotiation are risk management decisions rather than being truly Medicare Secondary Payer (“MSP”)-oriented. Once you understand why CMS wants what it wants, you will realize that its preference may not be the only way to achieve MSP compliance. The Complete Guide to Medicare Secondary Payer Compliance will help you take control of your insurance settlements by explaining how to:

avoid pitfalls and delays under CMS’ policies and procedures

comply with reporting requirements and avoid penalties

identify cases to submit for CMS review

achieve better CMS outcomes and avoid overly inflated MSAs

find defensible and less costly allocations for future medical expenses

submit acceptable proof for rated ages for purposes of CMS review

avoid rejection of MSA proposals for inadequate prescription drug information

understand MSA evaluations and financial options for funding MSAs

determine when MSAs should be used in liability settlements and the settlement language to use

and much more

Next year will mark the 10th anniversary of the infamous Patel Memo and the dawn of the MSA, and while the need for MSP compliance has achieved new levels of acceptance by the insurance and legal industries at large, confusion over compliance issues still abound. While it is true that the MSP is but one mere section of many statutes that govern the Medicare program, it is also true that many of the tasks that are undertaken today in furtherance of compliance are not expressly stated. But this statute has teeth and its reach is seemingly endless. It reaches beyond the underlying laws that give rise to the MSP obligation itself, and even beyond the parties to the original claim. It is an illusive area of law that few fully comprehend. And given the financial exposure for non-compliance by attorneys themselves, even beyond the potential harm to their clients created by the negligence of not addressing MSP obligations in their settlements, MSP education is clearly advised. The Complete Guide to Medicare Secondary Payer Compliance is designed to help attorneys, employers, insurance companies, labor representatives, and others navigate this complex area of the law. The handbook combines expert analysis of the substantive law with practice tips and other helpful tools and is organized as follows:

REFERENCE DIRECTORY provides you with a list of helpful contact information for government agencies as well as useful websites for conducting further research.

PART I, GUIDE TO MSP COMPLIANCE contains expert analysis of the substantive law organized as follows:

• Chapter 1, Development of MSP Enforcement, sets forth the background of the MSP, its history and purpose, and policy development by CMS.

• Chapter 2, MMSEA Section 111 Reporting Requirements, explains who must report and why, how reporting is accomplished, and the July 2010 changes in the MMSEA Section 111 User Guide.

• Chapter 3, Conditional Payments, addresses when Medicare is authorized to make primary payments when it is a secondary payer only if a primary payer has yet to make, or cannot reasonably be expected to make, a prompt payment, and how these payments are conditional in that they are conditioned upon reimbursement to Medicare, should it become apparent that the payments made were the responsibility of a primary payer.

• Chapter 4, Medicare Set-Aside Arrangements, covers when MSAs should be considered, the methodologies for MSAs, funding considerations, and MSA administration tools.

• Chapter 5, Workers’ Compensation Medicare Set-Aside Arrangements, discusses everything you need to know about WCMSAs, including the development of WCMSAs, CMS review program, timing of submissions, WCMSA calculation considerations, WCRC evaluation criteria, submission of WCMSAs, rated age and life expectancy, and WCMSA review and approval process.

• Chapter 6, Liability Claims and the MSP, analyzes the question of MSA use in liability settlements in the absence of clarification from CMS, sets forth the steps that should be taken to thoroughly document all MSP compliance steps as a means to lay out future defenses, and provides sample settlement agreement language that parties should use with caution and adapt to their cases.

PART II, CASE SUMMARIES WITH COMMENTARY surveys key court decisions interpreting the MSP, along with insightful and practical information written by Jennifer C. Jordan, Editor-in-Chief.

PART III, UNITED STATES CODE AND PUBLIC LAWS is a compilation of the relevant statutes and public laws relevant to the MSP.

PART IV, CODE OF FEDERAL REGULATIONS sets forth the relevant rules pertaining to the MSP.

PART V, MEDICARE SECONDARY PAYER (MSP) MANUAL is reprinted here as a helpful resource.

PART VI, MMSEA SECTION 111 USER GUIDE (July 12, 2010 version) is reprinted here as a helpful resource.

PART VII, CMS MEMORANDUMS are reprinted here as a helpful resource and includes the Patel Memo.

PART VIII, GLOSSARY AND ACRONYMS, compiled and written by Jennifer C. Jordan, Editor-in-Chief, serves as a useful guide to the MSP.

PART IX, UNITED STATES LIFE TABLES contains selected data from the 2006 tables and is provided here as a helpful resource.

INDEX, which is organized by topic and subtopics, helps you quickly find what you need in this handbook.

The Complete Guide to Medicare Secondary Payer Compliance was written by experts in the field, headed by Jennifer C. Jordan, Editor-in-Chief. Ms. Jordan is General Counsel at MEDVAL, LLC. She has become recognized nationally as an expert in Medicare Secondary Payer compliance. She has been an invited guest speaker at numerous industry events, for individual and trade organizations, and is a trusted advisor to several state agencies. She provides formal continuing education programs for nationally recognized providers, such as Lorman Education Services and WorkCompCentral, in both the MSP and structured settlements. She has been invited to write for various journals and national publications, such as the American Bar Association’s Tort, Trial and Insurance Practice magazine, The Brief. And most notably, her expertise has been recognized even by the United States Department of Justice, having been retained to consult in a constitutional claim brought against the Department of Health and Human Services in the Ninth Circuit in 2008. Ms. Jordan is a graduate of the University of Baltimore School of Law. She also holds two undergraduate degrees from the Virginia Polytechnic University and State University and a Master of Business Administration from the University of Baltimore Merrick School of Business.

Other contributors to the handbook are as follows:

 John V. D’Alusio, ARM, SCLA, Independent Consultant

 Robert T. Lewis, Crowe Paradis Services Corporation, Chief Legal Officer, Vice President of Sales & Marketing

 Robert G. Rassp, Law Offices of Robert G. Rassp

 Robert L. Sagrillo, Protocols, LLC, Founding Member

The Complete Guide to Medicare Secondary Payer Compliance is a living document. Given the rapid pace in which MSP law is developing, we plan to issue a new edition each year. An interim supplement will also be issued to keep you abreast of the latest changes in the law until the next edition of this handbook is issued. Feedback and suggestions are welcomed from readers.

To preorder the book, call 1-800-223-1940. To view the flyer for the bookclick here. The book is scheduled to ship to customers in late October. For further inquiries, contact