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10 South LaSalle Street, Suite 900, Chicago, IL 60603

211 Landmark Drive, Suite C2, Normal, IL 61761

211 North Broadway, Suite 2200, St. Louis, MO 63102

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20 Medicare Tips for 2020

January 2020

By: Marina Takagi Cobb, MSCC

    GENERAL TIPS:

  1. Start early! When preparing an initial analysis of a workers’ compensation claim, keep note of: claimant’s date of birth, Social Security Disability status, and Medicare entitlement date, in order to initiate a Medicare investigation early.

  2. The BCM Medicare Compliance Department is available to assist with any Medicare-related issues throughout the pendency of a claim. Please do not hesitate to contact us at any time during your case. It is never too early or too late!

  3. The low-dollar review thresholds for liability, no-fault, and workers’ compensations cases remain $750.00, effective January 1, 2020.

Medical Investigation & Argument Wins Over CMS

January 2019

By: Marina Takagi Cobb

The Firm was defending a Comp case brought by a petitioner who initially asserted an injury to his foot. While diagnostic imaging of the right foot and ankle showed no fractures, petitioner continued to complain to his orthopedic surgeon of not only right foot pain but, also, right knee discomfort. He asserted he had to “twist(ed) the leg” in the accident. The surgeon diagnosed a right foot crush injury, a right foot contusion, and a right knee sprain/strain, for which the petitioner underwent conservative treatment. Within a month of the alleged incident, the orthopedic surgeon noting the petitioner was exaggerating symptoms and complaints, released him from treatment, and sent him back to full duty.

The petitioner then sought a second opinion from another orthopedic physician. This time, the petitioner alleged right hip pain that was exacerbated by the work incident. The petitioner also complained of shoulder pain and low back pain.

Medicare "Liens": Departure From The Past Continues With Medicare Advantage Plans and Private Causes of Action

June 2018

When Medicare was created in 1965, the original legislation made Medicare "secondary" to workers' compensation (WC), and Medicare was not supposed to pay for any expenses that were covered under a WC claim. In 1980, Congress expanded this idea into the area of liability and no-fault cases. For years, insurers, attorneys, and parties to litigation could simply contact Medicare and negotiate a resolution of any medical bills paid by Medicare that were related to a particular claim. In the past decade or so, Medicare has ramped up its efforts to collect "conditional payments," so-named because Medicare pays the bills on condition that the "primary" insurance will later reimburse Medicare. The Centers for Medicare and Medicaid Services (CMS) has set up two different contractors to handle conditional payments: the Benefits Coordination & Recovery Center (BCRC) and the Commercial Repayment Center (CRC), and different procedures apply to each contractor, including differentiating the party or parties with whom Medicare will even communicate. Failure to pay back conditional payments can subject a primary plan to double damages, interest, and litigation costs. As labyrinthine as this system may already seem, any liable party or insurer needs to beware that the BCRC and CRC only handle "traditional" Medicare, which includes Medicare Part A (hospitalization) and Part B (medical) coverage where Medicare has made payments directly to the health care providers.

LMSAs: Is 2018 the Year?

June 2018

As we enter into the second half 2018, the anticipation surrounding reform of Medicare Set-Asides (MSAs) in liability and no-fault claims is growing. However, recent discussions by CMS reveal that it is not likely any formal process will be adopted soon. Over the last nearly 20 years, The Centers for Medicare and Medicaid Services (CMS) has provided a number of guidelines, thresholds, and policies for navigating the MSA process in Workers’ Compensation claims. However, the same has not been formalized for liability and no-fault claims … yet. All signs seem to point to potentially big changes for Liability Medicare Set-Asides (LMSAs) in the near future. Or at least in the future.

What are these signs of change? Initial rumblings of the formalization of the LMSA process started back in 2016. At that time CMS announced intentions to plan a series of town hall meetings to address reforms. Then, CMS advised Medicare and its contractors, effective October, 2017, to begin rejecting medical claims submitted post-resolution of a liability settlement on the basis the claims should be paid out of an LMSA. In concert with its search for a new set-aside review contractor in 2017, the CMS “job posting” requested the contractor provide review of liability and no-fault MSA submissions in addition to workers’ compensation MSAs. The amount of the contract with the new reviewer was purported to be more than 10 times the dollar amount received by the previous contractor. Speculation loomed that the large increase in the contract value signaled an increase in the expected workload if/when voluntary submission thresholds were added for Liability and No-Fault MSAs.

The Crystal Ball: Using Medical Investigation to Predict Future Medical Exposure

June 2018

By Marina Takagi

With cases involving complicated medical issues, the idea of shutting down medical rights due to potential future medical exposure seems daunting and unpredictable. However, with thorough medical investigation, BCM’s Medicare Compliance Department is able to foresee potential exposure for a Medicare Set-Aside Arrangement (MSA), and recommend the best legal course of action to resolve the claim.

In such a case, the petitioner was a younger employee that alleged exposure to chemicals in the workplace. This was the beginning of the petitioner’s extensive treatment for scleroderma, Raynaud’s syndrome, pulmonary fibrosis, and systemic sclerosis. Ultimately, the petitioner underwent a lung transplant. Following the transplant, the petitioner continued treatment required to avoid transplant rejection, as well as treatment to combat numerous infections.

Illinois Court Decisions Hints at Future of Medicare Advantage Reimbursement

March 2018

The Medicare Secondary Payer statute clearly states Medicare coverage is secondary to “primary” plans, which include workers’ compensation, liability, or no-fault insurance. If Medicare pays for medical services that should have been paid by a primary plan, Medicare can sue the plan for reimbursement of those payments.

Recent federal court decisions have expanded the term “Medicare” to include the private carriers who offer Medicare Advantage under Medicare Part C. The practical consequences are significant. If you have a claimant who is a Medicare beneficiary and you contact Medicare to conduct a search of conditional payments, Medicare may inform you there are none. But it may be unaware of benefits provided by Medicare Advantage. For such claims the reimbursement information can come only from the specific insurance carrier providing that claimant’s Medicare Advantage coverage. Making it even harder to get accurate information regarding Medicare Advantage, a claimant can change between Medicare Advantage insurers or switch back and forth from Advantage coverage to traditional Medicare. Adding to the confusion, many claimants’ attorneys have little or no clue how to assist with Medicare issues. An effective Medicare compliance program needs to consider and address Medicare Advantage, as well as traditional Medicare.The Medicare Secondary Payer statute clearly states Medicare coverage is secondary to “primary” plans, which include workers’ compensation, liability, or no-fault insurance. If Medicare pays for medical services that should have been paid by a primary plan, Medicare can sue the plan for reimbursement of those payments.

  • Chicago Bar Association
  • Workers' Compensation Lawyers Association
  • IRTB
  • DRI - The Voice of the Defense Bar
  • The Illinois Association of Defense Trial Counsel
  • Illinois Self-Insurers' Association
  • Chicago Bar Association
  • Workers' Compensation Lawyers Association
  • IRTB
  • DRI - The Voice of the Defense Bar
  • The Illinois Association of Defense Trial Counsel
  • Illinois Self-Insurers' Association
10 South LaSalle Street, Suite 900
Chicago, IL 60603
Phone: 312-425-3131
211 Landmark Drive, Suite C2
Normal, IL 61761
Phone: 309-862-4914
One Metropolitan Square
211 North Broadway, Suite 2200
St. Louis, MO 63102
Phone: 314-300-0527
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