Download NEW Medicare Set-Aside

INDEX
I.
The Step-by-Step Guide on Medicare “Set-Aside(s)”
p. 01 - 08
II.
The Medicare Secondary Payer Recovery Portal - MSPRP
p. 09
III.
Forms
p. 10 - 45
A.
NGHP Correspondence Cover Sheet
p. 10
B.
Client Information Worksheet
p. 11 - 13
C.
Proof of Representation
p. 14
D.
Rights & Responsibilities Letter
p. 15 - 17
E.
CPL Demand Letter
p. 18 - 19
F.
Payment Summary Form
p. 20 - 28
G.
CPL Related/Unrelated Work Sheet
p. 29 - 39
H.
Final Settlement Detail Document
p. 40
I.
Procurement Cost Worksheet
p. 41
J.
Beneficiaries CPL Dispute Letter
p. 42 - 43
K.
BCRC Final Demand (before Procurement Cost)
p. 44 - 45
THE STEP-BY-STEP GUIDE ON MEDICARE “SET-ASIDE(S)”
AND
HOW TO APPEAL AND/OR DISPUTE A LIEN AMOUNT
By: George “Boo” Hollowell
The Centers for Medicare & Medicaid Services (CMS) has completed the
restructuring of the Coordination of Benefits (COB) and Medicare Secondary Payer (MSP)
recovery activities, and this website (www.msprcinfo.com) is no longer accessible.
Information that was previously obtained from this site is now located on CMS.gov and can
be accessed via the following links:
Coordination of Benefits & Recovery Overview:
http://go.cms.gov/cobro
Attorney Services:
http://go.cms.gov/attorney
Beneficiary Services:
http://go.cms.gov/bene
Insurer Services:
http://go.cms.gov/insurer
The new entitiy that coordinates the Medicare recovery activities is the Benefits
Coordination & Recovery Center (BCRC).
CONTACTS:
Benefits Coordination & Recovery Center (BCRC)
BCRC Customer Service Representatives are available to assist you Monday through Friday, from
8:00 a.m. to 8:00 p.m., Eastern Time, except holidays, at toll-free lines:
1-855-798-2627 (and TTY/TDD: 1-855-797-2627 for the hearing and speech impaired).
Non-Group Health Plan (NGHP) Inquiries and Checks
NGHP
P. O. Box 138832
Oklahoma City, OK 73113
Self-Calculated Conditional Payment Amount Option and Fixed Percentage Option
Self-Calculated Conditional Payment Amount/Fixed Percentage Option
P. O. Box 138880
Oklahoma City, OK 73113
Fax: 1-405-869-3309
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**To increase efficiency, when sending a check or correspondence to the BCRC you may include
a NGHP Correspondence Cover Sheet (See Form “A”)
. The NGHP Correspondence Cover Sheet is available in the Downloads section of the NonGroup Health Plan Recovery page.
**Please mail MSP General Correspondence (e.g., information relative to Coordination of
Benefits) to:
Medicare - MSP General Correspondence
P. O. Box 138897
Oklahoma City, OK 73113-8897
Fax:
1-405-869-3307
ADDITIONAL CONTACT INFORMATION:
Contact 1-800-MEDICARE (1-800-633-4227) to:
*Obtain general Medicare information
*Obtain information about Medicare Health Plan Choices
*Order Medicare publications.
Contact the My.Medicare.gov help desk (1-877-607-9663) for:
*Assistance with MyMedicare.gov
Contact Social Security Administration (1-800-772-1213) to:
*Enroll in the Medicare program.
*Replace your Medicare card.
*Change your address.
*Verify Medicare coverage.
CMS.gov
A federal government website managed by the Centers for:
Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
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1.) When you agree to accept a workers’ compensation, personal injury and/or
Wrongful Death Client, obtain the following information in order to protect your client and
yourself from future liability for Medicare payment(s) made on behalf of your client.
(CAVEAT: Medicare has a $1,000.00 settlement amount threshold in order for
Medicare to seek reimbursement).
a.
Clients’ name, last known address, and a phone number (Deceased client, if
applicable).
b.
Type of Claim: (Liability Insurance, No-Fault Insurance, or Workers’
Compensation)
c.
Clients’ date of birth and gender.
d.
Clients’ date of death (if applicable).
e.
Clients’ Health Insurance Claim Number (HICN)/Medicare Number.
f.
Date of injury / accident / illness.
g.
A description of alleged injury/accident/illness. In addition, if you are
familiar with ICD-9 codes, include the ICD-9 code(s) with each
injury/accident/ illness for best results.
(ICD-9 Code site we use: www.ICD9data.com)
h.
Name and address of Workers’ Compensation carrier (if applicable).
i.
Name, address and phone number of Attorney.
(* “Client” will be the same whether for a workers’ compensation claim,
injury claim, and/or wrongful death claim.*)
(**See Form “B” - “Client Information Worksheet”)
2.)
You must file either a Proof of Representation or Consent to Release with the BCRC.
If you want to represent a beneficiary, communicate with and provide information to BCRC
then you must file a Proof of Representation. However, if you only want information such as
conditional payment information but you are not representing the beneficiary, then file a
Consent to Release. My suggestion is to always file the Proof of Representation Form
(See Form “C”).
(CAVEAT: Must write client name and HICN at the right hand top corner of each and
every page you send to BCRC or they will NOT accept).
3. )
The BCRC representative will inform all parties associated with your client’s case that
they shall receive a “Rights And Responsibilities” (RAR) letter (See Form “D”) if the Proof
of Representation or Consent to Release is submitted.
4.)
If you do not receive the “Rights And Responsibilities” (RAR) letter within three (3)
weeks of contacting the BCRC, call the BCRC at 1-855-798-2627. Follow the prompts until a
representative is on the line. Inform the BCRC representative you have NOT received the
“Rights And Responsibilities” (RAR) letter and that you have spoken with a specific BCRC
representative at a certain date and time documented on your Client Information Worksheet .
The representative will instruct you as to what must be done to receive this letter. If the BCRC
needs additional information and/or documentation, they will first attempt to contact you by
phone; however, if they are unsuccessful, they will mail you a letter.
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5.)
You should receive the “Conditional Payment Letter” (CPL) (See Form “E”) within
sixty-five (65) days of the date on the “Rights And Responsibilities” (RAR) letter. The
“Conditional Payment Letter” includes the amount BCRC claims to be related. Further, they
will attach a “Payment Summary Form(s)” (PSF) (See Form “F”).
NOTE:
A Conditional Payment Notice (CPN) is issued in lieu of a CPL when a
settlement, judgment, award or other payment has already occurred. Once
you receive this CPN, you must respond within thirty (30) days or you will lose
all rights to reductions for fees or costs.
a.
Prepare a “Related/Unrelated Worksheet” (See Form “G”) based on the
“DIAGNOSIS/ ICD” codes listed on the “Payment Summary Form(s)”. After
preparing your summary, you will then decide if you want to dispute the BCRC
claim set out in the CPL.
b.
If you are satisfied with the amount in the CPL, fax a “Final
Settlement Detail Document”(See Form “H”) to BCRC requesting a “Final
Demand Letter” be generated. You should include an executed Settlement
Agreement, Employment Contract, Attorney’s expense(s) Sheet,
Disbursement Sheet (if applicable), and your “Procurement Cost Worksheet”
(See Form “I”). In the “Final Settlement Detail Document”, make sure you
reduce the amount owed BCRC by the “Procurement Cost”, See Form “I”. You
should receive a “Final Demand Letter” from BCRC usually within thirty (30)
to sixty (60) days. You must send a check on or before the date set out in the
Final Demand Letter or interest will be charged from the date set out in the Final
Demand Letter.
Procurement Costs are set out in accordance with 42C.F.R. Part 411.37
as in the following EXAMPLE:
EXAMPLE:
Line 1 Amount of Settlement
$135,000.00
Line 2 Medicare Payments
$ 7,164.43
Line 3 Attorney’s Fees
$ 54,000.00
Line 4 Expenses
$ 13,726.96
Line 5 Line 3 plus 4
$ 67,726.96
Line 6 Line 5 divided by line 1
50%
Line 7 Line 2 x line 6
$ 3,582.21
Line 8 Line 2 minus line 7
$ 3,582.22
Line 8 - Based on this calculation, the amount of your related claim is $ 3,582.22.
This is your reduced Medicare lien amount.
Line 2 - Medicare Payments of $ 7,164.43 is the final amount owed (before Procurement
Costs(s) are applied).
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c.
If you dispute the amount demanded in the CPL, send your
“Related/Unrelated Worksheet(s)” along with the same documents in
5.)b. above to the address set out in the CPL. Also include all documents,
medical records, depositions, and opinions that will support your position as to
what is unrelated. You may want to use portions of the Defendant(s) expert
opinions and/or depositions to support your position, but be careful. You will
receive a response within forty-five (45) days. (See Form “J”)
d.
Once you receive this response from BCRC, (See Form “K”) if you are
dis-satisfied, you will then appeal in accordance with the instructions in said
letter. (The Lucy May Example Form “K” is the Final Demand Letter from
BCRC without the Procurement Costs reduction. Therefore, you should
respond by preparing another Procurement Cost(s) Worksheet (See Form
“I”) and submitting it with a check for the new amount you have
to the address set out in the Final Demand Letter.
calculated
The BCRC 5-LEVEL Administrative Appeal Process Steps:
LEVEL 1:
Receive Conditional Payment Letter from BCRC with Payment
Summary Forms attached - (Payment Summary Forms include detailed
information such as dates, organizations, ICD-9 Codes, etc.). Send BCRC a
“REQUEST FOR REDETERMINATION “ (With ALL supporting documents
attached, i.e. medical records, related/unrelated claims worksheet,
Procurement Cost Worksheet) within one hundred-twenty (120) days.
Receive notice/letter from BCRC of Redetermination Decision either
reducing the beneficiaries lien according to the supporting documentation you
sent in, or the BCRC’s lien amount stays the same (with their reasons as to why
listed in the notice/letter )within sixty (60) days.
(*May want to Appeal to next level).
LEVEL 2:
Send “Request for Redetermination” to party listed in BCRC’s notice and/or
letter of response. (i.e., a “Qualified Independent Contractor”/QIC). Send all
requested information and/or documents with your request and any other
supporting documentation within one hundred and eighty (180) days.
Receive notice/letter from BCRC/QIC of Redetermination Decision within sixty
(60) days.
(*May want to Appeal to next level).
LEVEL 3:
Send a “Request for Hearing before an Administrative Law Judge (ALJ)”; if
you have $140.00 in controversy, you have sixty (60) days to appeal. Include any
information and/or documentation they request and any other supporting
documentation you feel necessary to support your claim(s). You will receive a
“Notice Of ALJ Hearing” with date, time, name of the Administrative Law
Judge (ALJ) and any other pertinent information for a telephonic Hearing. You
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LEVEL 4:
LEVEL 5:
must send a copy of ALJ Request For Hearing to all parties of the QIC’s
decision.
(*This is usually a unilateral Hearing, in other words, Medicare does not
participate.)
(*Depending upon the decision made from the telephonic Hearing, the
next steps may be required.)
The decision will be given within ninety (90) days.
Fill out and send a “Request for Review of an Administrative Law Judge (ALJ)
Medicare Decision/Dismissal” form, including any requesting
information/documentation they may ask for and any other supporting
documentation to support your claim(s) within sixty (60) days.
You should receive a written decision within ninety (90) days from the Appeals
Council.
If you disagree with the Council’s decision in Level four (4), you have sixty (60)
days to request a judicial review by a Federal District Court.
The “NOTICE OF DECISION OF MEDICARE APPEALS COUNCIL” will
set out your right to court review and the procedure to follow to file your case in
the Federal District Court. (The minimum jurisdictional amount for 2013-2014
is $1,400.00)
I have successfully filed an Appeal in the United States District Court for the Northern
District of Mississippi, Greenville Division, in the case of “Mattie Young As Administratrix Of
The Estate Of Mattie Sue Delaney v. Secretary Of Health And Human Services”, CIVIL
ACTION NO: 4:11CV002-B-A in which the Court reversed and remanded the final decision
of the Secretary of Health and Human Services. The Court found that both the ALJ and
Medicare Appeals Council mis-stated the law and that “Medicare bear(s) the ultimate burden
of justifying the amounts it seeks in reimbursement.” Urso v. Thompson, 309 F. Supp. 2d
253, (D. Conn. 2004). The court explained that
recipients of Medicare benefits... are perhaps in a better position as an initial
matter to evaluate the reimbursement claim and to assess whether a payment
made by Medicare was truly for an item or service that was untimely paid by
the primary plan. But even if a Medicare recipient had the initial burden of
making a prima facie case that Medicare’s reimbursement requests were
overinclusive, it is the Secretary who should bear the ultimate burden of persuasion
on this issue, since it is the Secretary who is seeking reimbursement. A Medicare
subscriber . . . should not bear the burden of proving a negative.” Urso, 309 F.
Supp. 2d at 260.
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Other Options To Pay Medicare Lien
These options are available before Final Judgment or Settlement
1.)
THE SELF-SERVICE OPTION:
2.)
SECTION 201 OF THE SMART ACT: Use the Portal to determine the Final
This is a means to obtain Conditional
Payment Information via the telephone and without having to speak with a Customer
Service Representative. To use this option, call 1-855-798-2627 and select the SelfService option. When you use the Self-Service option you will need the Case ID, the
beneficiary’s Medicare number, date of birth and last name.
Demand. First you must settle within one hundred twenty (120) days of filing and CMS
will respond within sixty-five (65) days. If you dispute BCRC’s amount, you can
challenge it and CMS must respond within eleven (11) days or the amount you claim
will be automatically accepted. If CMS does respond, it will be placed on portal and you
may appeal if you are not satisfied.
3.)
FIXED PERCENTAGE OPTION: If a settled case meets certain eligibility
criteria, a beneficiary or his/her representative may request that Medicare’s demand
amount be calculated using the Fixed Percentage Option. The Fixed Percentage Option
offers a simple, straightforward process to obtain the amount due Medicare. It
eliminates time and resources typically associated with the MSP recovery process since
you will not have to wait for Medicare to determine the conditional payment amount
prior to settlement. You may elect the Fixed Percentage Option, if the following
eligibility criteria are met:
A.
Your liability insurance (including self-insurance) settlement, judgment,
award or other payment is related to an alleged physical trauma- based
incident and;
B.
The total settlement is for $5,000.00 or less.
4.)
THE SELF-CALCULATED CONDITIONAL PAYMENT OPTION:
This option enables you to self-calculate the final conditional payment amount before
settlement in certain situations. The following conditions must be met for Medicare to
provide the final conditional payment amount before settlement is reached:
A.
The claim and settlement must be for an injury caused by physical
trauma. The settlement cannot involve or relate to injuries caused by
exposure, ingestion, or medical implant.
B.
Your medical treatment for the injury must be completed with no further
treatment expected. Treatment must have been completed at least 90
days before you submit the proposed conditional payment amount to
Medicare.
C.
These requirements are proven to Medicare by providing either: A
physician’s written confirmation or beneficiary certification that he/she
has not had care related to the case within the last 90 days and expects no
further care.
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D.
E.
F.
The total settlement, judgment, award, or other payment cannot exceed
$25,000.00.
The date of the incident must have occurred at least six months before
submitting the self-calculated final conditional payment amount to
Medicare.
You will be asked to give up the right to appeal the amount or existence
of the debt. However, you will keep the right to pursue waiver of
recovery.
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The Medicare Secondary Payer Recovery Portal - (MSPRP)
The Medicare Secondary Payer Recovery Portal (MSPRP) is a web-based tool
designed to assist in the resolution of Liability Insurance, No-Fault Insurance, and Workers’
Compensation Medicare recovery cases. The MSPRP gives you the ability to access and update
certain case specific information online.
MSPRP Features & Benefits:
The MSPRP provides you with the following features and related benefits:
1.) Submit a Proof of Representation OR Consent To Release documentation
2.) Request conditional payment information:
* Request an updated Conditional Payment Amount
* Request a copy of a current Conditional Payment Letter
3.) Dispute claims included in the Payment Summary Form(s) attached to the CPL:
* View the claims listed on the Conditional Payment Letter’s Payment Summary
Form(s) and dispute unrelated claims
* Upload documentation to support the claim dispute
4.) Submit case settlement information:
* Input settlement information and upload a copy of the settlement documentation
How To Access The MSPRP
Attorneys and Insurers will access the MSPRP using the MSPRP Application Link found in
the Related Links section. However, registration must occur before access to the MSPRP is
permitted.
MSPRP User Manual
The MSPRP User Manual was written to help you understand how to use the MSPRP. The
User Manual is available under the “Reference Material” menu option of the MSPRP
application.
Assistance with MSPRP Issues
For problems related to registration and other technical issues, please contact the Benefits
Coordination & Recovery Center (BCRC) EDI Department at 1-646-458-6740.
For questions related to a case or why an MSPRP option is unavailable (i.e., grayed out),
please contact the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627.
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