The Medicare reporting issue is known by multiple names:

• Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007
• MMSEA Section 111
  Medicare Secondary Payer (MSP) Mandatory Reporting Requirement

A brief history of the Medicare Secondary Payer law includes:

• The  MSP law was first passed in 1980, but enforcement has been historically lax. 
  MSP requires Medicare to be the Secondary Payer of health benefits in situations where another entitity is the Primary Payer.
• If Medicare pays for items or services where the Primary Payer should have paid, Medicare can seek reimbursement.

Most recently changes have been enacted to enforce the law extremely aggressively:

• In 2007 Congress enacted new rules to enhance enforcement of the MSP law.
• The SCHIP Extension Act of 2007 requires all Primary Payers to determine if a claimant is entitled to Medicare and report to Medicare if appropriate.
• Fines ($1000 per day) and sanctions associted with non-compliance have gotten attention nationwide.
• The reporting program is being administered by the Centers for Medicare and Medicaid Services (CMS).

As a result any entity that makes payments to Medicare-eligible individuals needs to have an understanding of these new rules enacted by Congress to prevent vulnerability to such liability and penalties.

There is still uncertainty surrounding the question of who needs to comply.  The law is actually broad and covers entities making a payment that may cover medical expenses to potential Medicare beneficiaries.  A Responsible Reporting Entity (RRE) must report payments as a result of a:

• Group Health Plan (GHP)
• Settlement
• Judgment
• Award or other payment from liability insurance (including self-insurance), no-fault insurance, or workers' compensation

Recent changes to the Non-Group Health Plan User Guide make the insurer the RRE in many cases.  The RRE does have options in terms of who can execute their reporting, but the RRE remains liable for compliance/reporting.  Reporting options include:

• The RRE can report directly
• Third Party Administrators (TPS's) can be utilized to conduct the technical reporting process and function as the RRE's agent
• The RRE is considered the responsbile party and is responsible for any non-compliance

In workmens' compensation,  liability, and no-fault and other types of injury related claims, Medicare's interest has to be taken into consideration when the oposing parties settle.  Monies must be set-aside (Medicare Set-Asides) to cover future medical costs resulting from the injury.  This law is intended to force the opposing parties to include future medical costs resulting from the injury in the settlement amount, so that the cost is not shifted to the government while the injured party pockets money that should have gone to pay for care. Future Projections must be Medicare allowable expenses and are subjected to review by CMS. 

Under these circumstances it is best to utilize companies that are experienced with MSA allocation that can expedite the issues appropriately to include:

• Medicare lien evaluations
• Identifying impacted claimants
• Assisting with MSP mandatory reporting
• Providing medical cost projections
• Preparing detailed allocation reports
• Developing life care plans
• Providing complex nursing reviews
• Providing pharmaceutical drug reviews   

Medicare Lien Evalution is an evaluation of the claim to determine if the claimant is obligated under MSP and subject to a Medicare lien.  Not all payments made by Medicare are considered "conditional payments" (payments made by Medicare on behalf of the claimant that are related to the injury in question).  Each payment has to be evaluated separately to determine if it qualifies as a "conditonal payment" under the terms of MSP.

Future Medical Cost Projections (FMCP) provide the claims professional with an unbiased third party estimation of the total medical, durable medical equipment (DME), and prescription drug value of the claim.  This is a useful tool for setting accurate reserves and can be a key component for settlement negotiations.  It is ideal in situations where a Medicare Set-Aside (MSA) is not yet appropriate.

The FMCP report is based on the medical records and reports from all treating providers as well as the payment history and the pharmacy benefit management (PBM) report where applicable.  The report provides a medical summary that includes the initial injury information as well as current treatment, the future medical needs and any pre-existing or co-morbid conditions.  The report includes an itemized spreadsheet that lists the costs for all medical, DME and pharmacy needs on an annual basis as well as priced out for the life expectancy of the individual.

Complex Nursing Reviews are used to assist claims professionals in getting a true and accurate reflection of the medical cost.  Complex nurse reviews consist of a nursing audit, peer review, and medical bill review to conclusively determine the appropriate medical allowance for the claim.  This provides the claimant's attorney with a powerful negotiating tool adding value to the claim.

Pharmaceutical Drug Review is a comprehensive review of prescription drugs noting the medications with high exposure.  A review of the prescription drug history and medical records by a Pharmacologist provides accurate defensible recommendations and optimizes the prescription drug component of the MSA.

For more information on how we can assist you with Medicare mandatory reporting requirements, applicaton of The SCHIP Extension Act of 2007, and Medicare Set-Asides, contact us at:

1-877-347-6557

info@cook-legalnursing.com

Disclaimer:

Information provided on this web site is intended to be general in nature and does not serve as medical and/or legal advice.  Every effort has been made to provde up-to-date, accurate content; however, Cook & Associates Legal Nurse Consultants does not warrant or guarantee accuracy or completeness of information on web sites linked to this site.

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Our MSA consultants can educate you on how this law applies to  you or your business and guide you through the reporting process to assist in development of a Medicare Compliance Plan.  If you have questions regarding Medicare reporting please contact us today.