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Aug 1, 2016

US District Court: Ruling in Sexton vs. Medicare

In Sexton v. Medicare, 2016 U.S. Dist. LEXIS 89818, Medicare made conditional payments for Plaintiff’s treatment after Plaintiff was injured in a motor vehicle accident. After the conditional payments were made, Medicare issued a conditional payment letter to Plaintiff notifying him that Medicare had paid $678.80 for treatment of his accident-related injuries and that he may be required to reimburse Medicare for medical expenses related to his liability claim in the future. T

US District Court: Plaintiff Responsible for Full Amount of Formal Demand

Melisa Zwilling

Mar 23, 2016

US District Court: Plaintiff Responsible for Full Amount of Formal Demand

In Anderson v. Burwell, 2016 U.S. Dist. LEXIS 26633 (March 3, 2016), a case arising out of the United States District Court for the Eastern District of Michigan, Southern Division, the Court upheld the Administrative Law Judge’s decision requiring Plaintiff to reimburse Medicare for the full amount of the formal demand, rather than the amount of the prior Conditional Payment Letter (CPL). After Barbara Anderson passed away on September 20, 2006, Roland Anderson (Plaintiff), a

Melisa Zwilling

Jan 28, 2016

Court Dismisses Takemoto Qui Tam Action

On January 20, 2016, the US District Court for the Western District of New York issued an order dismissing the claims of Kent Takemoto against numerous defendants 2016 U.S. Dist. LEXIS 6468. In his complaint, Takemoto alleged that countless insurer, self-insurer and TPA defendants violated the Medicare Secondary Payer Act by “knowingly and improperly” avoiding their “obligation to reimburse the United States for payments made to Medicare beneficiaries.” The court found tha

NOW LIVE: Obtain A Final Conditional Payment Amount Prior to Settlement

Melisa Zwilling

Jan 11, 2016

NOW LIVE: Obtain A Final Conditional Payment Amount Prior to Settlement

It’s here! The ability to obtain a Final Conditional Payment Amount prior to settlement has gone live. As we discussed in November, as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP was to be modified to include a new functionality allowing authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that a final conditional payment amount is provided. CMS’ Decembe

Determining Rights of Medicare Advantage Plans: State Lacks Jurisdiction

Melisa Zwilling

Dec 10, 2015

Determining Rights of Medicare Advantage Plans: State Lacks Jurisdiction

In the most recent decision in a series of cases involving a 2009 incident at a condominium, a Florida Court of Appeal finds that the lower court erred in finding subject matter jurisdiction when determining the recovery rights of a Medicare Advantage Plan. Ms. Reale, the plaintiff in the present case, was injured in 2009 at a condominium insured by Western Heritage. Humana, a Medicare Advantage Plan, paid for treatment related to that injury. Humana originally pursued recove

Why It's Important: Timely Resolution of Conditional Payment Claims

Melisa Zwilling

Dec 10, 2015

Why It's Important: Timely Resolution of Conditional Payment Claims

In Iowa Supreme Court Atty. Disciplinary Bd. v. Silich, No. 15-1227, 2015 Iowa Sup. LEXIS 97 (Iowa, December 4, 2015), a complaint was brought by the state disciplinary board against an Iowa plaintiff’s attorney, Paul Silich, after it took him thirty-three months to resolve the Medicare lien in his clients’ liability case. Silich represented the conservator for the son of the deceased injured party as well as Clinton National Bank, the administrator of the injured party’s est

Update: Changes to Conditional Payment Claim Recovery Process

Melisa Zwilling

Dec 4, 2015

Update: Changes to Conditional Payment Claim Recovery Process

In October, a new contractor, the Commercial Repayment Center (CRC), began handling conditional payment claim recovery for claims in which CMS is pursuing recover directly from the primary payer. As you might imagine and may have already experienced, the new contractor has brought many changes to the conditional payment claim recovery process. One of those changes concerns the authorization required for the CRC to provide information to an applicable plan’s agent and has been

Reminder: Changes to Conditional Payment Claim Recovery Process

Melisa Zwilling

Oct 5, 2015

Reminder: Changes to Conditional Payment Claim Recovery Process

As we previously reported, beginning October 5, 2015, the Commercial Repayment Center (CRC) will handle the recovery of conditional payment claims when CMS is pursuing reimbursement directly from the primary payer. The Benefits Coordination and Recovery Center (BCRC) will still handle the recovery process when CMS is pursuing reimbursement from the beneficiary. CMS has indicated that the CRC may pursue recovery from the RRE when ORM has been reported under Section 111 or w

Melisa Zwilling

Sep 22, 2015

CMS Webinar Recap

On September 17, 2015, CMS held a webinar to discuss the new role of the Commercial Repayment Center (CRC) in the NGHP recovery process. Beginning October 5, 2015, the CRC will handle the recovery of conditional payment claims when Medicare is pursuing reimbursement directly from the primary payer. CMS indicated in the webinar that the CRC will primarily pursue recovery from the primary payer in cases in which ORM has been reported under Section 111 or the primary payer has

Melisa Zwilling

Aug 21, 2015

Recent Results

Below are just a few of our recent results! Our goal is to exceed our clients expectations and deliver results. We work tirelessly to do that in every case. •Filed for reconsideration of a $438,305 MSA requested by CMS. We submitted documentation and substantive arguments in support of our request. CMS issued a new approval for $284,507. Client Savings = $153,798 • File was referred to us for a second opinion after MSA allocation from another vendor was more than $80,000.

Melisa Zwilling

Aug 21, 2015

Join us at Booth #1025!

Dust off your leg warmers, tease up your hair, come celebrate the 80s with Carr Allison at Booth #1025 Be there or Be square! Register to win a $100 Visa Gift Card! Workers' Compensation Institute's 70th Annual Educational Conference August 23-26 2015, at Orlando World Center Marriott #WCConference #WorkersCompensation #MedicareSetaside #Section111 #MedicareSecondaryPayer #CarrAllisonMedicareCompliance

Melisa Zwilling

Aug 6, 2015

Upcoming Conferences

We hope to see you this summer at: Alabama Self-Insurer's Association Summer Conference August 9-11, 2015 at Hilton Sandestin Resort Come visit with us at Booth #9 and register to win $100 Visa Gift Card and at: Workers' Compensation Institute's 70th Annual Educational Conference August 23-26 2015, at Orlando World Center Marriott Come visit with us at Booth #1025 and register to win $100 Visa Gift Card #WCConference #CarrAllisonMedicareCompliance

Delaware Superior Court: MAOs Importance in the Medicare System

Melisa Zwilling

Aug 6, 2015

Delaware Superior Court: MAOs Importance in the Medicare System

In Honey v. Bayhealth Medical Center, Inc., 2015 Del. Super. LEXIS 378, a Superior Court in Delaware recently bolstered the importance given to Medicare Advantage Organizations in recent months by finding that, with regards to the application of the state’s collateral source rule, an MAO is subject to the same limitations as Medicare, rather than those attributed to private insurers. This determination supports the status that MAOs have been gaining recently within the court

US District Court: Contractual Obligation Does Not Demonstrate Primary Payer Responsibility

Melisa Zwilling

Aug 2, 2015

US District Court: Contractual Obligation Does Not Demonstrate Primary Payer Responsibility

In MSPA Claims 1, LLC v. Liberty Mut. Ins., No. 1:15-cv-21417-UU, 2015 U.S. Dist. LEXIS 99188 (S.D. Fla. July 22, 2015), an individual was injured in a motor vehicle accident. The individual had personal injury protection (PIP) insurance through Liberty Mutual Insurance and a secondary policy through Florida Healthcare Plus (FHCP), a Medicare Advantage Organization (MAO). FHCP conditionally paid for the insured’s medical expenses and later assigned its right to reimbursement

Case Study: Are Unnecessarily High MSAs Driving your Settlements Out of Range?

Melisa Zwilling

Jul 21, 2015

Case Study: Are Unnecessarily High MSAs Driving your Settlements Out of Range?

Quite often we are asked to provide second-opinion review of MSA allocations that were prepared by another vendor. We have consistently found that a majority of those allocations are incredibly inflated and include unnecessary treatment and medications. Though inflated MSA allocations help ensure a high CMS approval rating, they drive many settlements out of range. In cases that are able to settle, they cost a tremendous amount of money that simply does not need to be spen

Melisa Zwilling

Jul 17, 2015

CMS Update: Section 111 NGHP User Guide

On July 13, 2015, CMS issued an updated Section 111 NGHP User Guide. In an effort to prevent false positives in partial SSN searches, CMS increased the number of additional criteria needed to return a match. When submitting a beneficiary using a partial SSN of five digits, all four of the remaining criteria- first initial, surname, date of birth, and gender- must now be matched exactly. Additionally, the new User Guide replaces the term “TPA” with “recovery agent” and provide

Melisa Zwilling

Jul 17, 2015

CMS Alert: ICD-10 Reporting Reminder

CMS issued an alert as a reminder that Responsible Reporting Entities and their agents must report ICD-10-CM diagnosis codes on claim reports with a CMS date of incident on or after October 1, 2015. The apparent intention of this alert is to emphasize that the timing of this reporting requirement has not changed. The full text of the alert can be found here. #CarrAllisonMedicareCompliance #ICD10 #RRE #CMSUpdate

Section 111: Rule on Penalties Not Expected Until December 2016

Melisa Zwilling

Jun 24, 2015

Section 111: Rule on Penalties Not Expected Until December 2016

Under the SMART Act, CMS is supposed to issues rules specifying "practices for which sanctions will and will not be imposed." In December, 2013, CMS issued an Advanced Notice of Proposed Rulemaking seeking comments on circumstances in which penalties should and should not be imposed. The comment period closed in February, 2014 and since then the industry has been awaiting proposed rules from CMS. After CMS issues proposed rules, the public will be allowed to submit comment

Melisa Zwilling

Jun 18, 2015

CMS Alert: Matching Criteria for SSNs

On June 18, 2015, CMS issued an Alert entitled "Modification of Matching Criteria Used When Reporting Partial Social Security Numbers for Liability Insurance (Including Self-Insurance), No Fault Insurance, and Workers’ Compensation." The text of that alert is copied below: New Matching Criteria for Partial SSNs In order to determine if individuals are Medicare beneficiaries, the following information is used: •HICN or SSN •First initial of the first name •First 6 characters

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