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Frightening!

Medicare Set Aside Services — Thu, 04 Dec 2008 09:53:43 GMT

It makes you wonder just how often this must happen if Medicare feels the need to issue national coverage determinations to prevent payment.

Workers' Compensation Review Center take note….Medicare no longer covers "surgery on the wrong body part" so please do not include these services in your independent review!

Medicare Update

CMS Proposes National Coverage Determinations for Preventable Surgical Errors

Posted: 04 Dec 2008 12:43 AM CST

On December 2, 2008, the Centers for Medicare & Medicaid Services (CMS) proposed 3 national coverage determinations (NCDs) to establish uniform policies that will prevent Medicare from paying for certain serious, preventable errors in medical care. The proposed NCDs are:

Surgery on the Wrong Body Part

Surgery on the Wrong Patient

Wrong Surgery Performed on a Patient

CMS will be accepting public comments on the proposed coverage policies until January 1, 2009. CMS reports that comments should be submitted separately for each of the NCDs. Following the 30 day public comment period, CMS expects to issue final NCDs within 60 days.

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Caught in the legal recession?

Medicare Set Aside Services — Tue, 18 Nov 2008 12:04:27 GMT

With the current state of the economy, the ABA is surveying lawyers about the job market and its impact on the profession. To participate, follow this link to their survey.

The case for annuities AND professional administration

Medicare Set Aside Services — Thu, 13 Nov 2008 14:21:17 GMT

This inquiry received through the comments section of our blog says it best:

" My question is I have a 300.000 msa annuity that I want to sale what would I have to do to sale it for a lump some".

Fortunately for all concerned, annuities purchased on behalf of workers' compensation claimants cannot be transferred for a lump sum. So while it doesn't look like complying with the self-administered MSA guidelines is high on this claimant's to-do list, at least not all of his/her Medicare Set-Aside funds can be squandered in year one.

Improper use of the “donut hole” in Part D calculations

Medicare Set Aside Services — Tue, 11 Nov 2008 12:01:10 GMT

A recent discussion on the NAMSAP listserv focused on the improper use of the “donut hole” in Part D calculations, at least in the context of workers’ compensation settlements. The donut hole was an ill-considered solution to the problem of expanding Part D allocations and has realistic potential to be the subject of litigation in the future.

Along with other industry sales gimmicks like free file copies, medically baseless DURs, guaranteed MSAs and the latest promise of full MMSEA compliance in exchange for an exclusive MSA relationship, the donut hole was used more to gain market share than as a good faith effort to provide expertise in settlements involving the MSP.

From a practical standpoint, for those of us who are involved in the settlement process beyond just furnishing an MSA recommendation, the donut hole is a major impediment to settling a case and to the ongoing administration of a claimant’s Medicare Set-Aside. When faced with an inadequately funded MSA, the path of least resistance for both the claimant and their attorney is to simply refuse a settlement. Alternatively, informed attorneys request that additional funds be added to the settlement as compensation for the co-pays and deductibles that were excluded from the MSA. Either way, there is little real savings for the carrier, an increased burden of administration on the custodian/claimant and a long-tail liability created for all parties.

There are legitimate, defensible ways to minimize Part D allocations that do not jeopardize a settlement or compromise the reasonableness standard when protecting Medicare's interests. By our estimation, the donut hole is not one of them.

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Oct 29th, 2008 Q&A with CMS

Medicare Set Aside Services — Thu, 30 Oct 2008 15:06:04 GMT

Today, Centers for Medicare & Medicaid Service (CMS) hosted a conference call concerning the manadatory MMSEA (commonly referred to as SCHIP) reporting requirement for interested parties. Here is a document detailing the substantive issues addressed in the call.

Overall, CMS provided some additional clarity on the MMSEA reporting process and gave timelines when additional information would be forthcoming. Participants were encouraged to submit additional questions and suggestions via email for consideration by CMS in the planning process.

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Don't want/need Medicare?

Medicare Set Aside Services — Wed, 29 Oct 2008 09:17:39 GMT

For now the government says tough luck. And what is worse, if you do not enroll in Medicare then you also forfeit your social security benefits. This little known provision of Social Security policy was put into place in 1993 and strengthened again in 2002. If a person wishes to withdraw from or not enroll in Medicare, then they will lose their social security benefits, despite having paid thousands of dollars of taxes their entire working lives.

This policy is being challenged by a suit filed in the U.S District Court for the District of Columbia by three retired plaintiffs. They allege that the policy was improperly adopted with required public notice or hearings.

This issue intersects with Medicare Set-Asides in that we are often asked whether the requirement to protect Medicare's interests applies to a person who does not intend to use Medicare entitlements (such as the case with someone moving out of the country or a person that has private health insurance). The answer is always the same, the necessity of protecting Medicare interest through a Medicare Set-Aside or other arrangement lies in that person's entitlement to benefits not their intention to use them.

The bigger question is what public policy does it serve to force people into the Medicare system? If these three plaintiffs do not wish to receive Medicare why should they be forced to accept it? Why should taxpayers be forced to pay for benefits when these three plaintiffs have clearly made other arrangements for their post-retirement health care?

The Medicare Set Aside Gold Rush

Medicare Set Aside Services — Wed, 12 Nov 2008 09:13:26 GMT

There seems to be no end to the number of firms willing to hang a shingle and add Medicare Set Aside services to their service offerings. We always like to say that the Medicare Set Aside business looks deceptively easy from the outside and a bad MSA doesn't look much worse than a good one. Sometimes, they even look better. It seems anyone that attends the weekend course to get an MSCC certification feels perfectly comfortable holding themselves out as an expert regardless of actual experience while blissfully ignoring the damage they can do to their clients (whether working for the insurer or claimant).

Case in point. We were recently retained to evaluate a $650,000 MSA prepared by one of those PBM owned Medicare Set-Aside firms. Aside from the Medicare Set Aside being overfunded by approximately $350,000, the claimant was only 26 years old with a date of injury in 2004. Since he was 22 at the time of injury, it was immediately apparent that the claimant likely did not have enough quarters of earnings to be SSDI eligible. This fact was subsequently confirmed by a check with the Social Security Administration. So instead of a $650,000 MSA, the client needed a special needs trust and an MSA of $0.

So this Medicare Set Aside provider could have cost their client $650,000, rendered a severely injured claimant ineligible for government assistance and would probably keep right on whistling by the graveyard.

For Medicare Set Asides prepared by expert attorneys and medical professionals, call MEDVAL at 888-SET-ASIDE.

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Life Insurance agents use AIG turmoil to make a buck

Medicare Set Aside Services — Wed, 22 Oct 2008 12:45:10 GMT

Today, the New York Department of Insurance issued the following circular letter to licensed agents. One can infer from the tone of the letter that the Department has discovered that certain life insurance agents are using AIG's current difficulties to induce unsuspecting consumers into replace their AIG insurance contracts. By spreading fear, these agents are generating commisions selling replacement products that people don't need.

I guess that with hedge funds and wall street CEO's fleecing investors out of millions, the retail insurance agent wants to get in on the action. Whatever happended to making a dollar honestly, by providing products and services a consumer actually wants and/or needs?

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Market woes affect $42 million lottery winner

Medicare Set Aside Services — Fri, 10 Oct 2008 11:07:09 GMT

As a long-time structured settlement provider, we have often heard personal injury recipients decline a structured settlement because "they could do better investing themselves". Interestingly, the tide seems to be turning with the recent market turmoil and steep losses among all asset classes. However, everyone that has elected a structured settlement placed through us, has received 100% of their payments, tax-free, at a rate between 5% and 7%. Month after month, year after year, structured settlements have provided a safe, reliable rate of return. With their special treatment by Centers for Medicare & Medicaid Services (CMS) in Medicare Set-Aside arrangements, a structured settlement should be part of almost any personal injury settlement that requires Medicare's interests to be protected and where the claimant needs a reliable rate of return to meet his/her financial obligations.

This story by CNN illustrates the value of periodic payments in this economic environment.

LANSING, Michigan (AP) -- A winner of a $42 million Mega Millions jackpot in Michigan may do something almost unheard of: receive the money in installments rather than getting a smaller, one-time cash payment.
The winner of the October 3 jackpot indicated a preference for taking the annuity. State lottery spokeswoman Andi Brancato says she can't remember a Mega Millions winner in Michigan ever doing that since the game was launched in 2002.
The winner will be announced Friday at a news conference.
Lottery winners typically take a lump-sum payment with plans to invest it, but confidence in the market has dropped with the current financial crisis. The Dow has lost nearly 40 percent since closing at its all-time high a year ago.

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CMS Conference Call

Medicare Set Aside Services — Fri, 10 Oct 2008 11:03:28 GMT

SCHIP Implementation Guidance

During an October 1st conference call, Centers for Medicare & Medicaid Services (CMS) provided a basic outline of what Responsible Reporting Entities (RREs) for both Group Health Plans (GHPs) and non-GHPs (including Workers’ Compensation, Liability, Self-insurance and No-Fault Insurance) can expect in the coming months.

First and foremost, CMS emphasized that they are focusing on complete and accurate reporting and not the penalty phase of the Extension Act. For non-GHP RREs, a grace period of one year has been granted for identifying claimants who are Medicare beneficiaries and for whom the primary payment responsibility was established prior to 07/1/09. In an effort to assist RREs in identifying applicable claimants, CMS is currently consulting with counsel and investigating whether they can provide a system by which RREs can perform queries to determine whether an individual is Medicare eligible.

A timeline (available here) has been established to identify the times in which a RRE must register with the COBC through the Coordination of Benefits Secure Web site (COBSW). The COBSW has been identified as the portal through which all information will be submitted and communications will be received in response to submissions. Electronic registration for GHP RREs will run 04/01/09 - 04/30/09 and electronic registration for Liability, No-Fault, Self-Insured and Workers’ Compensation RREs is planned to take place 05/01/09 - 06/30/09.

Each RRE must register individually; registration by a designated agent for the RRE will not be permitted, but use of agents for reporting is permitted. The agent to be used must be identified during the registration period.

Upon registering through the COBSW, the RRE will be contacted by the COBC and assigned own dedicated Electronic Data Exchange Representative who will become the RRE’s personal contact at the COBC. The representative will work with the RRE and their technology staff to set up and test the data exchange process. The testing period for GHP is scheduled to occur 04/01/09 - 07/01/09 and will occur 07/01/09 - 09/30/09 for non-GHP RREs.

Once the trial has been determined to be successful, then the production phase will begin. GHP RREs will submit their first production files 07/01/09-10/01/09 and non-GHP RREs will begin submitting production files 10/01/09-12/31/09. The RRE or its agent will submit the required information and in return will receive both an acknowledgement of receipt and the COBC response file, which will notate any errors. These errors need not be corrected immediately, but in the next scheduled reporting. The COBC already has 200 firms completing daily exchanges and report that once established it is a very smooth process. More specifics regarding the type of information that is to be required will be published as the data element is still being developed for non-GHP.

Additional CMS sponsored Open Door Forum Teleconferences, User Guides and computer based training programs are expected to be released over the last quarter of this year. User guides for both GHP and non-GHP RREs are expected within the next 30 days.

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A wheelchair Medicare WILL NOT cover

Medicare Set Aside Services — Tue, 23 Sep 2008 17:05:43 GMT

In Geske, Germany the autobahn is not just for BMWs' and Mercedes' any longer. Former engineer and assumed workers' compensation claimant Guenther Eichmann, informed police he "souped up" his electric wheelchair when pulled over doing 40MPH, double the local speed limit. The punishment? Paying $600 in fines and forfeiting his hot rod wheelchair.

Medicare Fraud Strike Force Remains Active

Medicare Set Aside Services — Fri, 19 Sep 2008 11:36:00 GMT

On September 18, 2008, the Department of Justice (DOJ) announced in a Press Release that Medicare Fraud Strike Force (MFSF) agents arrested 18 individuals in the greater Los Angeles area for their alleged roles in Medicare fraud schemes totaling more than $33 million.

According to the Press Release, the arrests involved durable medical equipment owners, medical professionals, and medical clinic owners who allegedly engaged in various Medicare fraud schemes, including schemes involving power wheelchairs, orthotics, hospital beds, enteral nutrition and feeding supplies.

In May 2007, the DOJ and Department of Health and Human Services (HHS) announced in a News Release that the MFSF began operations in March 2007 and had already resulted in 38 arrests and indictments involving over $142 million in Medicare billings. At the time of the announcement, HHS revealed that the MFSF used "real-time analysis of billing data" to identify and react to fraud schemes.

Since May 2007, MFSF efforts have yielded a steady stream of arrests and indictments. In fact, the DOJ reports in the Press Release that federal prosecutors have indicted 103 cases with 175 defendants in both Los Angeles, California and Miami, Florida since 2007. The DOJ also claims that these defendants fraudulently billed the Medicare program for more than half a billion dollars.

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AIG Fallout on Structured Settlements

Medicare Set Aside Services — Wed, 17 Sep 2008 09:58:06 GMT

This week, AIG has been teetering on the verge of bankruptcy and sending shockwaves through the financial system. Last night, with the announcement of an $85 billion credit facility, the Federal Reserve with explicit backing from the Treasury, stepped in to prevent the insurance giant's collapse. Market analysts agree that Wall Street has been changed forever.

Here on main street, clients began removing American General from their annuity approved lists fearing that AIG's collapse would spill over into American General. We think this is probably an overreaction for several reasons. American General is a separately capitalized and regulated life insurance company. Mismanagement in one arm of AIG (insurance contracts on complex derivatives) has no bearing on the financial strength of American General. Furthermore, American General often has the best rates and rated ages of anyone in the business. Are carriers willing to pay $5,000 to $100,000 or more for a Medicare Set-Aside or Custodial Medical Account to protect against an unlikely default by American General? Removing American General is going to cost firms millions of dollars in higher annuity premiums to solve a problem that probably doesn't exist.

However, even though we don't like to see the removal of American General from the marketplace, it is probably the only decision that our client's could make. How does the average broker or claim representative explain that they are placing an annuity (supposedly one of the safest and most secure investments available) with a firm that has AIG in its name? In financial markets, perception is reality and the reality is that AIG/American General will have to wait until the dust settles before being able to write structured settlement business. We hope that they can quickly extricate themselves from this mess because there is no finer group of people in the industry.

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CMS Releases new policy memo

Medicare Set Aside Services — Thu, 04 Sep 2008 16:59:44 GMT

In a memo dated 08/25/2008, Centers for Medicare & Medicaid Services addresses several important aspects of the Medicare Set-Aside process.

First, CMS has released policy regarding pricing of implantable devices. In the example given, Spinal Cord Stimulators now must come with specific rationale for the pricing used. In the past, in contradiction of CMS policy and defying all logic and reasonableness, the WCRC simply used a fixed amount for a SCS regardless of jurisdiction or fee schedule. MEDVAL has always used the new methodology outlined in the memo and now CMS apparently agrees with our approach.

But Medicare Set-Aside allocators be forewarned. In CMS’s own words "Effective with WCMSA submissions received by the Centers for Medicare & Medicaid Services’ (CMS’) Coordination of Benefits Contractor on or after September 1, 2008, if the WCMSA proposal includes the pricing for any Implantable Device(s) and does not include enough information as illustrated on the sample, "Pricing for a Spinal Cord Stimulator," or if the WCMSA proposal does not include pricing for any Implantable Device(s), and it is determined upon review of the WCMSA proposal, an Implantable Device(s) is recommended for the claimant and CMS will then utilize its own cost-finding methodology". Emphasis added because that's just plain scary.

Second, CMS has rescinded prior guidance that will allow parties to petition CMS for release of the set-aside funds if certain conditions were met. Never mind that carriers and claimants probably agreed to and funded higher Medicare Set-Asides than reasonable with the promise that the work of the WCRC could be undone after five years with the benefit of hindsight. For now, unless some disenfranchised claimant comes forward to represent the class and challenge this policy on its constitutional merits, CMS has just "protected the trust fund" on the backs of unsuspecting payers. Generally, well crafted public policy dictates a grandfather clause when new legislation affects prior, irrevocable decisions. Even the IRS gets that.

Finally, Centers for Medicare & Medicaid Services has strengthened the language of determining life expectancy via a rated age. Now the submitter must certify that they used all of the rated ages obtained. The problem with using a median rated age is that rated ages have little to no bearing on a claimant’s actual life expectancy. Rated ages are used primarily by life insurance companies to make their annuity rates more or less competitive for a given class of claimants. It makes no sense that a 42 year old quadriplegic rated standard by Met Life (because they don’t want the business) should be averaged with a 65 year old rating from Liberty Life (who does and is comfortable with the risk). Individual rated ages have no bearing on a claimant’s actual life expectancy. Plus, the life companies and structured settlement brokers sure must be tired of providing rated ages for the convenience of CMS.

We applaud the pricing methodology for implantable devices. We deplore CMS’s decision to rescind the ability to petition for redress of a poorly reviewed Medicare Set-Aside (of which there are many). And the rated age guidance will have little to no effect since brokers will learn to only give the Medicare Set-Aside companies the highest rated age since they are not a party to the attestation requirement. Besides, insurance company provided rated ages have no place in determining actual life expectancy any more than the WCRC has in predicting a claimant’s future medical needs. But then again CMS proved in its May 2008 memo that it did not actually care about empirical proof of life expectancy as compiled by the CDC when it implemented the universal use of Table 1 which totally disregards sex, race and any other contributing factors that have been proven to effect life expectancy.

Career Opportunities

Medicare Set Aside Services — Fri, 29 Aug 2008 12:50:07 GMT

As a rapidly growing company, MEDVAL is always looking for experienced professionals to join our team. We take pride in knowing that we offer one of the most unique and integrated approaches to the Medicare Set-Aside process in the industry.

UPDATE: In addition to our ongoing national recruiting efforts, we have immediate openings in our Pittsburgh, PA office for paralegals, attorneys, and nurse case managers with MSA experience.

For more information about careers at MEDVAL, apply through our website at www.medval.com.

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CMS Publishes hospital quality of care statistics

Medicare Set Aside Services — Thu, 04 Sep 2008 16:28:19 GMT

On Wednesday, Centers for Medicare and Medicaid (CMS) published a tool on their website that provides information on how well the hospitals care for all their adult patients with certain medical conditions or surgical procedures. For the first time, consumers of medical treatment can objectively research the quality of care obtained at various hospitals.

The data can be accessed at www.hospitalcompare.hhs.gov

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Medicare Update

Medicare Set Aside Services — Tue, 19 Aug 2008 07:57:46 GMT

Centers for Medicare & Medicaid Services

CMS Reports Lower Medicare Part D Costs Than Expected in 2009

The Centers for Medicare and Medicaid Services (CMS) recently announced in a Press Release that, based on bids submitted by Medicare Part D plans, CMS estimates that the average monthly premium that beneficiaries will pay for standard Part D coverage in 2009 will be $28.

CMS reports that this is approximately 37 percent lower than the original estimate for 2009 of $44.12, which was made at the time the Medicare Prescription Drug, Improvement and Modernization Act of 2003 was enacted. CMS also reports that the average expected premium for basic coverage in 2009 is about $3 higher than the actual average for 2008. CMS attributes the $3 increase to general trends in drug costs, the phase out of a CMS demonstration project, and higher plan estimates for catastrophic coverage based on prior experience.

In addition to announcing the average premiums for 2009, CMS also announced: (i) the 2009 national average monthly bid; (ii) the base beneficiary premium; (iii) the regional low income subsidy premium amounts for 2009; and (iv) the 2009 Medicare Advantage regional preferred provider organization benchmarks. That information can be found here.

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Thoughts on the U.S. Healthcare System

Medicare Set Aside Services — Thu, 14 Aug 2008 07:36:31 GMT

In his August 4th “Cheap, Fast or Good” blog post, Joe Paduda says:

“There are those on both sides of the political debate (and some who fancy themselves in the middle) who use anecdotes, scary stories, hyperbole and highly elastic versions of 'true' stories to support their solutions to our present health care insurance disaster. While both sides are guilty, I'd have to say the free marketers look to be 'guiltier.' Case in point - I'm on the distribution list (at least at the time of this writing) for a few PR firms that have been hired by conservative types to get bloggers to espouse the libertarian, it-ain't-broke-that-bad-so-don't-fix-it perspective on health care reform. And they tend to try to scare the crap out of everyone with horror stories of waiting lists in Canada, patients expiring in the UK on transplant lists, and folks with furrin accents invading American hospitals as they try to get kidneys or MRIs or gall bladder surgery without waiting till three years after they're dead. And these are the reputable folks - there's also a lot of misinformation circulating in the webosphere about bad Canadian health care”.

Maybe, maybe not. Who really knows after everyone gets their PR firms to slant the facts? But today, while attending an OB appointment, I got a first hand story of Finnish healthcare from our midwife who cares for an ailing 72 year old mother. The discussion centered around whether her mother would be eligible for Medicare as a non-US citizen (the answer is that she can “buy” Medicare Part A and Part B if she has lived in the US for at least five years, is at least 65 years old and has permanent resident status) and whether she would be better cared for here in the United States or under the socialized Finnish system.

Apparently several years back, while the mother was still in Finland, she was hospitalized for a bladder infection. Prior to being admitted, she told the doctors that she was predisposed to such infections and that was the likely cause of her current ailment. Despite her self-diagnosis, this poor lady spent three months in the hospital before being properly diagnosed! The conclusion? No way was this US certified midwife going to send her mother to lanquish back in Finland.

So that’s it, point proved, no further discussion needed on US health policy.

And it was a girl!

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CMS Publishes Proposed Guidelines for SCHIP Extension Act Compliance

Medicare Set Aside Services — Wed, 13 Aug 2008 17:14:56 GMT

Last week, the Centers for Medicare and Medicaid Services (CMS) published proposed guidelines in the Federal Register regarding implementation of the new liability and no-fault reporting requirements set forth in Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007. CMS's recommendations for compliance with the new reporting requirements are published in the Federal Register with an invitation for public comments on the methods for collecting and submitting such information and the means of enhancing the quality of data.

When the Extension Act was passed in December 2007, the statute required that, beginning July 1, 2009, insurers would be obligated to determine benefit status of all Claimants and report the claim to the Secretary of Health and Human Services to essentially put Medicare on notice so that its interests remain protected. Agencies that fail to comply with the reporting requirements will be fined $1,000 per day per claimant. At the time of this Act's passage, limited guidelines were issued to help insurers understand and meet CMS's expectations. These proposed guidelines are the first step in designing a process to simplify reporting requirements in conjunction with the Act.

In addition to the Federal Register publication, CMS has authored a Supporting Statement to further elaborate on proposed reporting guidelines. The Supporting Statement includes clarification on frequency of submitting information and field requirements (mandatory, optional, and situational). Additionally, it provides definitions for types of insurance plans obligated to comply with the new law.

All in all, we believe this is a solid effort on CMS's part to provide better guidance for compliance and expectations pending the implementation of the Extension Act next year. While the comments and concerns of the public and industry leaders may (and hopefully will) influence CMS such that this process becomes as efficient as possible, we expect that some guidelines will change over the months.

CMS has created the following website to follow instructions as they are developed: www.cms.hhs.gov/MandatoryInsRep/
and comments to the guidelines can be published at http://www.regulations.gov on or before September 30, 2008.

For questions and guidance about how to implement your own reporting protocol in advance of the July 1, 2009 deadline, contact MEDVAL or Ask Jen.

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GAO Sting Operation Reveals Ease of Medicare Fraud

Medicare Set Aside Services — Thu, 07 Aug 2008 07:55:56 GMT

This week, the Government Accountability Office (GAO) issued a report which revealed some glaring problems with CMS's ability to spot and avoid fraud in light of what has been deemed a pending solvency crisis.

The GAO created two fictitious durable medical equipment (DME) suppliers which spent the last year billing CMS for services and products despite that both "companies" did not provide complete documentation in their applications, owned no inventory, and served no clients. All three indicators should have provided ample evidence to CMS that further inquiry would have been appropriate. Although no CMS funds were misused in this experiment, the GAO stated that CMS has put "millions of dollars" at risk by failing to adequately verify supplier legitimacy. This should be a major concern for Medicare who has improperly paid over $1 billion for DMEPOS supplies between April 2006 and March 2007. CMS, while agreeing with the results of the study, issued a statement reminding concerned citizens and lawmakers that programs are being implemented to reduce what has recently become a major issue of Medicare fraud with initiatives such as the competitive bidding program for DMEPOS.

While CMS has established some programs and Congress has enacted statutes to protect its solvency (such as the Medicare Secondary Payer statute and the Medicare, Medicaid, and SCHIP Extension Act of 2007), this study proves that there continue to be many areas that the CMS administration overlooks. In fact, the GAO used words like "simple" and "easy" to describe the challenge to defraud Medicare for this study.

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