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Medicare Set Aside News - Several New Medicare Announcements

The Centers for Medicare & Medicaid Services announce several new changes for Responsible Reporting Entities and Providers related to Medicare Set Asides.

The Centers for Medicare and Medicaid Services (CMS) have announced in an Alert on June 15, 2012 that the proposed rules for Medicare Set Asides apply to future medicals in general and are not limited to liability as many speculated. There are seven options proposed: 1 – 4 applying to both beneficiaries and those with the "reasonable expectation," and 5 – 7 applying only to beneficiaries. No one option satisfies all possible Medicare Set Aside scenarios; therefore, it is assumed that more than one would be adopted if found to be feasible. The options are as follows:

  1. Total honor system where an individual pays for all related future medical until the settlement is exhausted and the person documents the case accordingly. There would be no CMS review of the Medicare Set Aside but it reserves the right to randomly audit records.
  2. Liability settlements with no Workers Compensation or No-Fault coverage that are at least a year old and essentially resolved will not be pursued by CMS for a Medicare Set Aside.
  3. MSP recovery limited to CPL with physician attestation of no future anticipated treatment. If date of completion is after settlement, future medicals would limited through that date.
  4. Current CMS Medicare Set Aside review program extended to liability settlements.
  5. If beneficiary participates in any of the new recovery options (settlement under $300, fixed payment or self-calculation), future medicals will also be considered satisfied as part of a Medicare Set Aside.
  6. Upfront payment options for ORM situations with CMS approval or liability settlements paying a specified percentage of net beneficiary proceeds.
  7. No future obligations in Medicare Set Aside cases where CMS granted compromise or waiver of recovery. All Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers' Compensation Responsible Reporting Entities (RREs) are not required to "Self-Report" Ongoing Responsibility for Medicals (ORM) outside of the MMSEA Section 111 reporting process.

Click here for the New CMS Alert.

CMS Provides Alerts for Reporting Thresholds

On June 20, 2012, the Centers for Medicare & Medicaid Services posted three new MMSEA Section 111 Alerts which focus on interim reporting thresholds. All TPOCs reported in year 2013 will have a minimum threshold of $5,000 and all TPOCs reported in year 2014 will have a minimum threshold of $2,000. The TPOC amount for claims reported in year 2015 previously set at $600, have now dropped to $300. The last alert extends the WC ORM exclusion indefinitely. These are the "medical only" claims with no lost time and all medical payments of no more than $750 paid directly to the medical providers.

CMS Provides Guidance for Medicare Billings & Physician Accountability

CMS has recently made changes to the Medicare Secondary Payer Manual to add "Clarification of Medicare Conditional Payment Policy and Billing Procedures for NGHP (Non Group Health Plans) Liability, No-Fault and Workers Compensation Medicare Secondary Payer (MSP) Claims."

There are several comprehensive changes included in what is known as Transmittal 86 for provider billing requirements when the common working file (CWF) indicates an MSP situation. Many of the new provisions also include checking to see if there is a GHP (Group Health Plan) that is primary to Medicare as well and waiting for the promptly period to expire before making conditional payments. It is clear that CMS intends to hold providers more accountable for determining MSP exclusions. The new changes give some insight into the post-settlement Medicare Set Aside world. Changes will not go into effect until year 2013.

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