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312-425-3131

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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21 More Medicare Tips For 2021

June 2021

In 2020, the Brady, Connolly & Masuda, P.C. Medicare Compliance Department (MCD) provided our top 20 tips and updates for the Medicare Secondary Payer world (https://conta.cc/2T6NjH4). Since then, we have all overcome new obstacles, developed innovative processes, and continued to advance the practice. With 2021 in full swing, the MCD presents 21 more tips and updates for you.

GENERAL INFORMATION:

  1. Start. Early! The MCD continues to emphasize early investigation into possible Medicare implications for your claims in order to avoid delay in resolution down the road.
  2. With that said…it is never too late. Whether the claimant is still treating, you have settled the claim, or the permanency portion of the claim has been closed for some time, the MCD can always offer recommendations to resolve possible Medicare-related issues throughout your claims.
  3. The low-dollar review thresholds for liability, no-fault, and workers’ compensation cases remain $750.00 in 2021.
  4. Rated ages are not only useful for future medical analyses, but can also decrease potential exposure for other aspects of claims. Please reach out to us if you need assistance with obtaining a rated age.

SECTION 111:

  1. The Provide Accurate Information Directly (PAID) Act was signed into law, which includes the provision, “Transparency of Medicare Secondary Payer Reporting Information.” The PAID Act will require the Centers for Medicare and Medicaid Services (CMS) to expand its Section 111 Query Process. CMS must implement the PAID Act by December 11, 2021.
  2. The PAID Act will require CMS to identify whether a claimant is currently entitled to, or has been entitled to for three years prior, Medicare Parts C and D (Medicare Advantage and prescription drug coverage, respectively). CMS will be required to provide names and addresses of any Parts C or D plans through the Query Process.
  3. A New Section 111 User Guide was released in January 2021. The MCD recommends communicating with your Section 111 vendor in order to provide accurate information, which could impact the outcome of later conditional payments cases.

MEDICARE SET-ASIDES:

  1. Updated Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guides were released in October 2020, and most recently, on April 19, 2021 (version 3.3, COBR-Q1-2021-v3.3).
  2. The updated WCMSA Reference Guide clarifies that, when an annuity is selected for a WCMSA, the “seed” includes the cost of the first surgery/procedure for each body part (including all costs such as prescription drugs, physician fees, anesthesia fees, and facility fees), plus the first two years of annual payments.
  3. Keep in mind that there are additional nuances to the calculation of the “seed” such as (among others):
    1. If a surgery involves a trial, such as a spinal cord stimulator or pain pump implantation, then the cost of the trial is also included as part of the “seed.”
    2. If there are no surgeries involved, then the first procedure is included in the “seed,” such as injections.
  4. The CDC Life Table was updated in the newest WCMSA Reference Guide—this should be reflected in your proposals, rated ages, and legal analyses.
  5. The updated WCMSA Reference Guide notes “CMS highly recommends professional administration where an individual is taking controlled substances that CMS determines are ‘frequently abused drugs’ according to CMS’ Part D Drug Utilization Review (DUR) policy.” (WCMSA Reference Guide Section 17.1). If you have a question in regards to self versus professional administration, the MCD can provide recommendations on a case by case basis.
  6. Medication pricing is updated in the WCMSA Portal once a month. Updated pricing will be used at the time that CMS is actually reviewing the WCMSA proposal. The MCD is able to monitor the pricing of medications in order to evaluate the fluctuations in future medical exposure (i.e. the price of Lyrica has decreased dramatically, which means a WCMSA including Lyrica may be ripe for submission).
  7. In some WCMSA approvals, surgeries have not been priced consistently. CMS should be sharing more information about this in short time. As it stands, CMS has not provided information regarding their formularies or pricing resources. We will continue to monitor CMS’ pricing methods, and update our clients.
  8. In regards to surgical pricing, the updated WCMSA Reference Guide includes a list of major medical centers used for surgical pricing. However, this has not completely remediated the discrepancies in surgical pricing, at this time.
  9. Professional administrators with WCMSA portal access can submit annual attestation information via portal. A professional administrator who was not the original submitter, may contact Medicare to gain access to the case via portal. Otherwise, attestation must be submitted by mail.
  10. The Consent to Release form for WCMSA submissions still requires the language indicating that the beneficiary has reviewed the submission package and understands the intent of the WCMSA process. This must be initialed by the beneficiary. The Consent to Release must also be signed and dated with a full name signature.
  11. Guidelines for Liability MSA’s (LMSA’s) are…you guessed it, still pending. CMS’ proposed rules were expected to be released in March 2021; however, this has been further continued. While we wait for a more formalized process, the MCD can provide guidance in evaluating future medical exposure for your liability claims.

CONDITIONAL PAYMENTS:

  1. The Medicare Secondary Payer Recovery Portal (MSPRP) continues to be updated. We are able to review Open Debt Reports, documents/correspondences sent between entities and parties, and submit settlement information. Future enhancements are also on the horizon for the MSPRP.
  2. At times, there are duplicate claims opened with the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC). For example, if the BCRC receives information that a claimant obtains a settlement or is moving toward a settlement, they will open a case. Once an entity issues a demand, the other entity should be locked out of adding claims. Once there is a Conditional Payments Notice, the case is locked in with the CRC. Once there is a final Demand, the case is locked in with the BCRC. However, there are still issues with duplicate cases opening and re-opening. The MCD can evaluate each case, monitor all open cases, and make sure that the correct entities are involved. We can work with all parties to have the required consent forms necessary to communicate directly with Medicare.
  1. As always, the Brady, Connolly & Masuda, P.C. MCD is available to assist with any of your Medicare Secondary Payer needs at any time!
  • 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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