Medicare in Personal Injury Claim Settlements: Complying ...media.straffordpub.com/products/medicare-in... · 24/03/2016 · Medicare is a government program providing health care

Presenting a live 90-minute webinar with interactive Q&A

Medicare in Personal Injury Claim Settlements:Complying With Reporting Requirementsand Satisfying Liens

1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific

THURSDAY, MARCH 24, 2016

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Today’s faculty features:

1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific

Jeremy T. Burton, Partner, Lipe Lyons Murphy Nahrstadt & Pontikis, Chicago

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Jeremy BurtonLipe Lyons Murphy Nahrstadt & Pontikis Ltd.

230 West Monroe Street, Suite 2260Chicago, IL 606006

(312) [email protected]

Trial and SettlementConsiderations

Introduction Considerations for Plaintiff ’s counsel Considerations for Defense counsel Settlement language Negotiating Settlement with the CMS

Introduction Considerations for Plaintiff ’s counsel Considerations for Defense counsel Settlement language Negotiating Settlement with the CMS

6

IntroductionMedicare is a government program providing health care.Under Medicare, the government reimburses health careproviders for covered care provided.

Until 1980, Medicare was the primary payer of all medicalcosts except in workers’ compensation cases.

After 1980, Medicare is always a secondary payer to liabilityinsurance, self-insurance, no-fault insurance, and workers’compensation insurance. Medicare is also a secondary payerto group health plan coverage in certain situations.

Medicare is a government program providing health care.Under Medicare, the government reimburses health careproviders for covered care provided.

Until 1980, Medicare was the primary payer of all medicalcosts except in workers’ compensation cases.

After 1980, Medicare is always a secondary payer to liabilityinsurance, self-insurance, no-fault insurance, and workers’compensation insurance. Medicare is also a secondary payerto group health plan coverage in certain situations.

7

Introduction

Insurers are not allowed towrite policies secondary toMedicare. Such policieswould supersede federallaw.

Insurers are not allowed towrite policies secondary toMedicare. Such policieswould supersede federallaw.

8

Introduction

Since 1980, Medicare beneficiaries, attorneys, insurers,self-insured entities, third party administrators and theiragents have been responsible for

(1) Understanding when there is coverage primary toMedicare,

(2) Notifying Medicare when applicable,(3) Paying appropriately.

Since 1980, Medicare beneficiaries, attorneys, insurers,self-insured entities, third party administrators and theiragents have been responsible for

(1) Understanding when there is coverage primary toMedicare,

(2) Notifying Medicare when applicable,(3) Paying appropriately.

9

Introduction

The new law, Section 111 of the Medicare, Medicaid andSCHIP Extension Act of 2007 (MMSEA Section)

“Adds mandatory reporting requirements with respect toMedicare beneficiaries who have coverage under grouphealth plan arrangements as well as for Medicarebeneficiaries who receive settlements, judgments,awards or other payment from liability insurance, no-fault insurance, or workers’ compensation.”

The new law, Section 111 of the Medicare, Medicaid andSCHIP Extension Act of 2007 (MMSEA Section)

“Adds mandatory reporting requirements with respect toMedicare beneficiaries who have coverage under grouphealth plan arrangements as well as for Medicarebeneficiaries who receive settlements, judgments,awards or other payment from liability insurance, no-fault insurance, or workers’ compensation.”

10

IntroductionImplementation dates for the new law were originally January1, 2009 for group health plans to register and July 1, 2009 forliability insurers to register.

Insurers must report claims with settlement dates on or after

October 1, 2011.*

In certain cases where an insurer has ongoing responsibilityfor medical claims, claims arising after January 1, 2010 mustbe reported.

Implementation dates for the new law were originally January1, 2009 for group health plans to register and July 1, 2009 forliability insurers to register.

Insurers must report claims with settlement dates on or after

October 1, 2011.*

In certain cases where an insurer has ongoing responsibilityfor medical claims, claims arising after January 1, 2010 mustbe reported.

11

Introduction*Reporting Thresholds

Not repayment thresholds

January 1, 2012 >$100,000

*Reporting Thresholds

Not repayment thresholds

January 1, 2012 >$100,000

July 1, 2012 >$50,000

October 1, 2012 >$25,000

January 1, 2013 >$5,000

January 1, 2014 >$2,000

January 1, 2015 >$1,000

12

IntroductionThe new law is designed to enforce the statutes passed in

1980.

It does not substantively change the pre-existingMedicare law and statutes. It adds new reporting rules. It includes penalties for noncompliance.

The new law is designed to enforce the statutes passed in1980.

It does not substantively change the pre-existingMedicare law and statutes. It adds new reporting rules. It includes penalties for noncompliance.

13

Considerations for Plaintiff’sCounselIntake Considerations

Is the client 65 or older?Receiving Social Security Disability?Suffering from end-stage renal disease?

Obtain your client’s Medicare identification cardAdvise Defense counsel

Intake Considerations

Is the client 65 or older?Receiving Social Security Disability?Suffering from end-stage renal disease?

Obtain your client’s Medicare identification cardAdvise Defense counsel

14

Considerations for Plaintiff’sCounselPleading Considerations

Any operative amended complaint must occur prior tothe date of settlement, judgment, award or otherpayment and must not have the effect of improperlyshifting the burden to Medicare by amending the priorcomplaint to remove any claim for medical damages.

Section 111 NGHP User Guide, Chapter III, 1-1. Version 4.5.

Pleading Considerations

Any operative amended complaint must occur prior tothe date of settlement, judgment, award or otherpayment and must not have the effect of improperlyshifting the burden to Medicare by amending the priorcomplaint to remove any claim for medical damages.

Section 111 NGHP User Guide, Chapter III, 1-1. Version 4.5.

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Considerations for Plaintiff’sCounsel

Lien Concerns

Explain to your client that a substantial portion of theirsettlement will be payable to Medicare.

Inform your client that Medicare costs may have asignificant impact on your chances to favorably resolvethe case.

Lien Concerns

Explain to your client that a substantial portion of theirsettlement will be payable to Medicare.

Inform your client that Medicare costs may have asignificant impact on your chances to favorably resolvethe case.

16

Consideration for Plaintiff’sCounsel

Future Medicals

Advise your client that Medicare has a right to recoverany amount they expend on future medical care. Youmay want to consider the availability of a special needstrust or other ways to escrow money for future medicalcosts.

Future Medicals

Advise your client that Medicare has a right to recoverany amount they expend on future medical care. Youmay want to consider the availability of a special needstrust or other ways to escrow money for future medicalcosts.

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Future Medicals

“You should also be aware that if you do not repayMedicare in full, it may decide to recover any amountsyou owe (including accrued interest) from any SocialSecurity or Railroad Retirement benefits to which youmight otherwise be entitled, or from future Medicarepayments.”

Future Medicals

“You should also be aware that if you do not repayMedicare in full, it may decide to recover any amountsyou owe (including accrued interest) from any SocialSecurity or Railroad Retirement benefits to which youmight otherwise be entitled, or from future Medicarepayments.”

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Penalty Provisions

42 C.F.R. Sect. 411.24(g)

Recovery from parties that receive primary payments.CMS has a right of action to recover its payments fromany entity, including a beneficiary provider, supplier,physician, attorney, State agency or private insurer thathas received a primary payment.

Penalty Provisions

42 C.F.R. Sect. 411.24(g)

Recovery from parties that receive primary payments.CMS has a right of action to recover its payments fromany entity, including a beneficiary provider, supplier,physician, attorney, State agency or private insurer thathas received a primary payment.

19


Penalty Provisions

U.S. v. Harris, 2009 WL 891931 (N.D.W.Va)

The CMS calculated the amount it was owed, aftersubtracting amounts for attorney’s fees and costs. The CMSmade its demand by letter, and after the statutory timeelapsed without appeal the government filed suit. The courtgranted summary judgment to the government and orderedthe Plaintiff ’s counsel to pay the judgment plus interest.

Penalty Provisions

U.S. v. Harris, 2009 WL 891931 (N.D.W.Va)

The CMS calculated the amount it was owed, aftersubtracting amounts for attorney’s fees and costs. The CMSmade its demand by letter, and after the statutory timeelapsed without appeal the government filed suit. The courtgranted summary judgment to the government and orderedthe Plaintiff ’s counsel to pay the judgment plus interest.

20

Considerations for DefenseCounsel

Discovery

Is the plaintiff a beneficiary?Has the plaintiff received benefits?What has the plaintiff done with respect to the lien?

Discovery

Is the plaintiff a beneficiary?Has the plaintiff received benefits?What has the plaintiff done with respect to the lien?

21


Discovery

Form A-1

Allows an insurer to determine whether the plaintiff is aMedicare beneficiary. Obtain with interrogatories.

Full name, Medicare claim number (HICN), date ofbirth, social security number and sex.

Discovery

Form A-1

Allows an insurer to determine whether the plaintiff is aMedicare beneficiary. Obtain with interrogatories.

Full name, Medicare claim number (HICN), date ofbirth, social security number and sex.

22


A completed A-1 form allows an insurer to query theBenefits Coordination & Recovery Center (BCRC) todetermine whether an injured party is a Medicarebeneficiary.

A completed A-1 form allows an insurer to query theBenefits Coordination & Recovery Center (BCRC) todetermine whether an injured party is a Medicarebeneficiary.

23


Reporting

Make certain your client – insurer or self-insured entity isregistered to report.

http://www.Section111.cms.hhs.gov

If a complaint or discovery lists the date of a plaintiff ’s injuryor exposure after December 5, 1980, Medicare will require areport.

Reporting

Make certain your client – insurer or self-insured entity isregistered to report.

http://www.Section111.cms.hhs.gov

If a complaint or discovery lists the date of a plaintiff ’s injuryor exposure after December 5, 1980, Medicare will require areport.

24

Considerations for DefenseCounselReporting

When a case involves continued exposure, Medicarefocuses on the date of last exposure to determinewhether the exposure continued after 12/5/80. Theapplication of the 12/5/80 date is specific to a particulardefendants.

Medicare will assert a recovery claim against exposureafter 12/5/80 if liability is claimed, released or effectivelyreleased.

Reporting

When a case involves continued exposure, Medicarefocuses on the date of last exposure to determinewhether the exposure continued after 12/5/80. Theapplication of the 12/5/80 date is specific to a particulardefendants.

Medicare will assert a recovery claim against exposureafter 12/5/80 if liability is claimed, released or effectivelyreleased.

25


When the following requirements are met, Medicare willnot assert a recovery claim and reporting is notrequired.

• All exposure ended before 12/5/80• Exposure has not been claimed in the most recently

amended complaint and/or specifically released.• There is no release for exposure after 12/5/80 or whether

there is a release it is a broad general release whicheffectively releases exposure.

Reporting

When the following requirements are met, Medicare willnot assert a recovery claim and reporting is notrequired.

• All exposure ended before 12/5/80• Exposure has not been claimed in the most recently

amended complaint and/or specifically released.• There is no release for exposure after 12/5/80 or whether

there is a release it is a broad general release whicheffectively releases exposure.

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The RRE does not make a determination of whatportion of any settlement is for medicals and whatportion is not.

If medicals are claimed and/or released thesettlement, judgment, award or other payment bust bereported regardless of any allocation made by theparties or a determination by the court.

Reporting

The RRE does not make a determination of whatportion of any settlement is for medicals and whatportion is not.

If medicals are claimed and/or released thesettlement, judgment, award or other payment bust bereported regardless of any allocation made by theparties or a determination by the court.

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The CMS is not bound by any allocation made by the partieseven where a court has approved such an allocations. TheCMS does normally defer to an allocation made through ajury verdict or after a hearing on the merits.

This issue is relevant to whether the CMS has a recoveryclaim and does not affect the RRE’s obligation to report.

Section 111 NGHP User Guide, Chapter III, 6-22, Version 4.5.

Reporting

The CMS is not bound by any allocation made by the partieseven where a court has approved such an allocations. TheCMS does normally defer to an allocation made through ajury verdict or after a hearing on the merits.

This issue is relevant to whether the CMS has a recoveryclaim and does not affect the RRE’s obligation to report.

Section 111 NGHP User Guide, Chapter III, 6-22, Version 4.5.

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NGHP RRE BCRC PrimaryPayer/Debtor

29


Third Party Administrators

The new Medicare reporting requirements arecomplicated enough that the CMS has anticipated thatRREs will hire Third-Party Administrators (TPAs) tohandle reporting and payment obligations.

42 U.S.C. 1396y(b)(7)&(8)

Third Party Administrators

The new Medicare reporting requirements arecomplicated enough that the CMS has anticipated thatRREs will hire Third-Party Administrators (TPAs) tohandle reporting and payment obligations.

42 U.S.C. 1396y(b)(7)&(8)

30


Medicare Penalties

Medicare beneficiaries are required to reimburseMedicare within 60 days of receipt of settlement.

If Medicare is not reimbursed by the beneficiary,payment becomes the responsibility of the primarypayer.

Medicare Penalties

Medicare beneficiaries are required to reimburseMedicare within 60 days of receipt of settlement.

If Medicare is not reimbursed by the beneficiary,payment becomes the responsibility of the primarypayer.

31

Why ReportThe CMS has a right of action to recover its paymentsfrom any entity, including a beneficiary, provider,supplier, physician, attorney, State agency or privateinsurer that has received a primary payment.

42 CFR Sec. 411.24(g)

The CMS has a right of action to recover its paymentsfrom any entity, including a beneficiary, provider,supplier, physician, attorney, State agency or privateinsurer that has received a primary payment.

42 CFR Sec. 411.24(g)

32

Why ReportIf Medicare is not reimbursed as required by paragraph(h) of this section, the primary payer must reimburseMedicare even though it has already reimbursed thebeneficiary or other party.

42 CFR Sec. 411.24(i)

If Medicare is not reimbursed as required by paragraph(h) of this section, the primary payer must reimburseMedicare even though it has already reimbursed thebeneficiary or other party.

42 CFR Sec. 411.24(i)

33

Why ReportThe United States can collect double damages and attorneysfees against any entity not paying under the new statute.

Furthermore,

An applicable plan that fails to comply with the Medicarereporting requirements is subject to a civil money penalty of$1,000 for each day of noncompliance with respect to eachclaimant. 42 USC Sec. 1395y(b)(8)(E)(i)

The United States can collect double damages and attorneysfees against any entity not paying under the new statute.

Furthermore,

An applicable plan that fails to comply with the Medicarereporting requirements is subject to a civil money penalty of$1,000 for each day of noncompliance with respect to eachclaimant. 42 USC Sec. 1395y(b)(8)(E)(i)

34


New Process

(1) Determine the Medicare status of all claimants(2) RRE must report settlements(3) RRE must resolve liens(4) RRE must give consideration to Medicare’s

interest in future payments

New Process

(1) Determine the Medicare status of all claimants(2) RRE must report settlements(3) RRE must resolve liens(4) RRE must give consideration to Medicare’s

interest in future payments

35

Considerations for DefenseCounselORM/TPOC and Date of Settlement

It may be but not always is the check date or paymentdate, it is the date the obligation is signed, if there’s awritten agreement, unless court approval is required. Ifcourt approval is required it is the later of the date theobligation is signed or the date of court approval. Ifthere is no written agreement it is the date the payment,or the first payment if there will be multiple payments isissued.

See http://www.cms.gov/MandatoryInsRep/Downloads/March11NGHPTranscript.pdf, pg. 15.

ORM/TPOC and Date of Settlement

It may be but not always is the check date or paymentdate, it is the date the obligation is signed, if there’s awritten agreement, unless court approval is required. Ifcourt approval is required it is the later of the date theobligation is signed or the date of court approval. Ifthere is no written agreement it is the date the payment,or the first payment if there will be multiple payments isissued.

See http://www.cms.gov/MandatoryInsRep/Downloads/March11NGHPTranscript.pdf, pg. 15.

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Medicare Set Asides

1. Medical damages fromthe date of injury throughthe date of settlement.

2. Future medical damagesfrom the date ofsettlement forward.

Medicare Set Asides

1. Medical damages fromthe date of injury throughthe date of settlement.

2. Future medical damagesfrom the date ofsettlement forward.

37

Medicare Set AsidesIn non-workers’ compensation cases, you are not required to set asidemoney for future damages to pay for plaintiff ’s future medical expenses.There is some disagreement on this topic. Many defense firms areadvising clients to set aside funds for future medical expenses. The CMShas confirmed that set asides are not required in liability cases, thoughthey have also noted that they “reserve their right” to both challengeagreements which do not adequately cover Medicare costs and the futureright to require set asides in liability cases.

You should consider something like a Medicare Set Aside (MSA) forfuture medical damages. This set aside is used in workers’ compensationcases to “reasonably protect Medicare’s future interests.”

If the CMS approves the proposed set-aside all parties will receive “safeharbor” protection from future government collection action.

In non-workers’ compensation cases, you are not required to set asidemoney for future damages to pay for plaintiff ’s future medical expenses.There is some disagreement on this topic. Many defense firms areadvising clients to set aside funds for future medical expenses. The CMShas confirmed that set asides are not required in liability cases, thoughthey have also noted that they “reserve their right” to both challengeagreements which do not adequately cover Medicare costs and the futureright to require set asides in liability cases.

You should consider something like a Medicare Set Aside (MSA) forfuture medical damages. This set aside is used in workers’ compensationcases to “reasonably protect Medicare’s future interests.”

If the CMS approves the proposed set-aside all parties will receive “safeharbor” protection from future government collection action.

38

Medicare Set AsidesUnfortunately, CMS is notin a position to review setasides at this time.

As an alternative you canmake a Claims SettlementAllocation (CSA).

Unfortunately, CMS is notin a position to review setasides at this time.

As an alternative you canmake a Claims SettlementAllocation (CSA).

39

Medicare Set AsidesThe following standards apply to MSAs in workers’compensation cases and should be taken into account inother liability cases.

A MSA is available where the claimant is currently a Medicarebeneficiary and the TPOC is greater than $25,000.

Or where the plaintiff will soon be a Medicare beneficiaryand the TPOC amount for future medical expenses, disabilityand lost wages is expected to be greater than $250,000.

The following standards apply to MSAs in workers’compensation cases and should be taken into account inother liability cases.

A MSA is available where the claimant is currently a Medicarebeneficiary and the TPOC is greater than $25,000.

Or where the plaintiff will soon be a Medicare beneficiaryand the TPOC amount for future medical expenses, disabilityand lost wages is expected to be greater than $250,000.

40

Medicare Set AsidesA MSA is not necessary where:

1. The facts of the case demonstrate that the injuredindividual is only being compensated for past medicalexpenses; and

2. There is no evidence that the individual is attempting tomaximize the other aspects of settlement to Medicare’sdetriment; and

3. The individual’s treating physicians conclude in writingthat, to a reasonable degree of medical certainty, theindividual will no longer require any Medicare-coveredtreatments related to the workers’ compensation injury.

A MSA is not necessary where:

1. The facts of the case demonstrate that the injuredindividual is only being compensated for past medicalexpenses; and

2. There is no evidence that the individual is attempting tomaximize the other aspects of settlement to Medicare’sdetriment; and

3. The individual’s treating physicians conclude in writingthat, to a reasonable degree of medical certainty, theindividual will no longer require any Medicare-coveredtreatments related to the workers’ compensation injury.

41

Medicare Set AsidesA MSA/CSA must show a good-faith consideration of futuremedical expenses.

Remember that expenses must be related to the injury and inthe appropriate case, you may want to consider a secondreview of medical records to eliminate overpaying forunrelated medical conditions.

Is there a need for a trust?

Can a Third Party administer the trust?

A MSA/CSA must show a good-faith consideration of futuremedical expenses.

Remember that expenses must be related to the injury and inthe appropriate case, you may want to consider a secondreview of medical records to eliminate overpaying forunrelated medical conditions.

Is there a need for a trust?

Can a Third Party administer the trust?

42

Medicare Set Asides

“We have continued to say with respect to set-asides orliability situations that set-asides are not required interms of CMS being involved in any type ofdetermination of how much the set-asides should be.We have also said that our regional offices have theability to evaluate proposed set-aside amounts forliability if their workload permits them to do so.”

“We have continued to say with respect to set-asides orliability situations that set-asides are not required interms of CMS being involved in any type ofdetermination of how much the set-asides should be.We have also said that our regional offices have theability to evaluate proposed set-aside amounts forliability if their workload permits them to do so.”

43

Medicare Set Asides“This is not the same thing as a blanket statement that liability set asidesare simply not required or not appropriate. Regardless of the mechanism,Medicare’s interests need to be protected. The statute says that we don’tmake payment where payment has already been made. Whether or notthis is protected through setting up a formal set-aside, setting up a formaltrust, simply keeping the money and insuring that it’s being [paid] in apriority manner to Medicare until the appropriate funds are exhausted;those are all choices, but we need to make it clear that’s not the samething as saying – and that we are not in fact saying that liability set-asidesaren’t appropriate.”

http://www.cms.gov/MandatoryInsRep/Downloads/Jan2810NGHPTranscript.pdf, pg. 17.

“This is not the same thing as a blanket statement that liability set asidesare simply not required or not appropriate. Regardless of the mechanism,Medicare’s interests need to be protected. The statute says that we don’tmake payment where payment has already been made. Whether or notthis is protected through setting up a formal set-aside, setting up a formaltrust, simply keeping the money and insuring that it’s being [paid] in apriority manner to Medicare until the appropriate funds are exhausted;those are all choices, but we need to make it clear that’s not the samething as saying – and that we are not in fact saying that liability set-asidesaren’t appropriate.”

http://www.cms.gov/MandatoryInsRep/Downloads/Jan2810NGHPTranscript.pdf, pg. 17.

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Medicare Set AsidesThe CMS has noted their “standard expectation is that theywill be pursuing recoveries against settlements received byindividual beneficiaries.” However the CMS further notesthat “there are limited instances where CMS has gone back toan insurer or to an attorney particularly if, for instance, anattorney for a beneficiary who ignores CMS’s demand,technically, there are some risks under the regulation. Is itany type of standard practice for us to routinely go back to aninsurer or attorney or other entity when we’ve issued thedemand to the beneficiary? No.”

See http://www.cms.gov/MandatoryInsRep/Downloads/Feb2510NGHPTranscript.pdf, pg. 37.

The CMS has noted their “standard expectation is that theywill be pursuing recoveries against settlements received byindividual beneficiaries.” However the CMS further notesthat “there are limited instances where CMS has gone back toan insurer or to an attorney particularly if, for instance, anattorney for a beneficiary who ignores CMS’s demand,technically, there are some risks under the regulation. Is itany type of standard practice for us to routinely go back to aninsurer or attorney or other entity when we’ve issued thedemand to the beneficiary? No.”

See http://www.cms.gov/MandatoryInsRep/Downloads/Feb2510NGHPTranscript.pdf, pg. 37.

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Creating Medicare Set AsidesIf both sides have obtained medical records in writtendiscovery, you likely have a blue print to create a successfulMSA.

If both sides have testimony from medical experts regardingpermanency and anticipated future medical damages you arein an even better position.

If one or both sides have hired an economist to analyze futuremedical needs, your work is almost complete.

If both sides have obtained medical records in writtendiscovery, you likely have a blue print to create a successfulMSA.

If both sides have testimony from medical experts regardingpermanency and anticipated future medical damages you arein an even better position.

If one or both sides have hired an economist to analyze futuremedical needs, your work is almost complete.

46

Creating Medicare Set AsidesAs a general rule in creating a set aside, your MedicareAllocation Report should include the following.

The beneficiary’s name The beneficiary’s address The beneficiary’s social security number The beneficiary’s current age The beneficiary’s life expectancy The date of the injury The state of jurisdiction

As a general rule in creating a set aside, your MedicareAllocation Report should include the following.

The beneficiary’s name The beneficiary’s address The beneficiary’s social security number The beneficiary’s current age The beneficiary’s life expectancy The date of the injury The state of jurisdiction

47

Creating Medicare Set Asides The related diagnoses and ICD-9 Diagnosis Codes An introduction and description of the injury A medical history including relevant doctors’ visits,

examinations, and surgeries Summaries of the relevant doctors’ visits, examinations,

and surgeries Physician diagnoses, prognoses, recommended course of

treatment and if available opinions on possible futuresurgeries and all future costs. A list of pre-existing and unrelated conditions

The related diagnoses and ICD-9 Diagnosis Codes An introduction and description of the injury A medical history including relevant doctors’ visits,

examinations, and surgeries Summaries of the relevant doctors’ visits, examinations,

and surgeries Physician diagnoses, prognoses, recommended course of

treatment and if available opinions on possible futuresurgeries and all future costs. A list of pre-existing and unrelated conditions

48

Creating Medicare Set Asides A summary of the plaintiff ’s current functional states and

ability to perform activities of daily living. A summary of the future treatment plan including doctors’

visits, future surgery, and anticipated prescription costs. A bottom line MSA number.

Your report should also contain the methodology utilized toexplain how you calculated the final number, e.g. adjustedlife expectancy and discount rate. The more you rely onverifiable medical information, the more protected you andyour client will be.

A summary of the plaintiff ’s current functional states andability to perform activities of daily living. A summary of the future treatment plan including doctors’

visits, future surgery, and anticipated prescription costs. A bottom line MSA number.

Your report should also contain the methodology utilized toexplain how you calculated the final number, e.g. adjustedlife expectancy and discount rate. The more you rely onverifiable medical information, the more protected you andyour client will be.

49

Settlement LanguageMadison County, Illinois has entered an order in Asbestos cases withhelpful suggested settlement language.

As part of settlement, Plaintiff ’s counsel must complete Medicare Form Bin order to finalize any settlement agreement.

Medicare Form B requires all of the same information contained in the A-1 form as well as information that Medicare requires such as the diagnosiscode for the plaintiff ’s illness, the name of the settling defendant, the dateof the settlement, the amount of settlement and information on thefunding of settlement.

Madison County, Illinois has entered an order in Asbestos cases withhelpful suggested settlement language.

As part of settlement, Plaintiff ’s counsel must complete Medicare Form Bin order to finalize any settlement agreement.

Medicare Form B requires all of the same information contained in the A-1 form as well as information that Medicare requires such as the diagnosiscode for the plaintiff ’s illness, the name of the settling defendant, the dateof the settlement, the amount of settlement and information on thefunding of settlement.

50

Settlement LanguageReleases should be tailored to discuss Medicare obligations. If there areno future medical damages, that should be stated in the release. Ifpossible, obtain indemnification, defense and hold harmless languagefrom the plaintiff ’s firm ensuring that a paying RRE will be protectedfrom double paying and double damages.

At the very least, all settlement agreements should state who isresponsible for investigating Medicare liens, and who is responsible forsatisfying any Medicare liens.

Releases should be tailored to discuss Medicare obligations. If there areno future medical damages, that should be stated in the release. Ifpossible, obtain indemnification, defense and hold harmless languagefrom the plaintiff ’s firm ensuring that a paying RRE will be protectedfrom double paying and double damages.

At the very least, all settlement agreements should state who isresponsible for investigating Medicare liens, and who is responsible forsatisfying any Medicare liens.

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Settlement LanguageThe language of the Madison County order notes that

(1) Defendant will not include Medicare on the settlement check.

(2) PLAINTIFF'S FIRM agrees to hold in its trust account sufficientfunds to pay all Medicare claims or liens relating to suchsettlement …or has in fact satisfied all Medicare claims or liensin full. PLAINTIFF'S FIRM will notify ... CMS, of any settlementwhich this Agreement governs and will work to satisfy orotherwise obtain discharge or release of any Medicare claim orlien including "set asides," if any.

The language of the Madison County order notes that

(1) Defendant will not include Medicare on the settlement check.

(2) PLAINTIFF'S FIRM agrees to hold in its trust account sufficientfunds to pay all Medicare claims or liens relating to suchsettlement …or has in fact satisfied all Medicare claims or liensin full. PLAINTIFF'S FIRM will notify ... CMS, of any settlementwhich this Agreement governs and will work to satisfy orotherwise obtain discharge or release of any Medicare claim orlien including "set asides," if any.

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Settlement Language(3) If defendant receives a claim for any unsatisfied Medicare claim

… defendant will notify PLAINTIFF'S FIRM … and request fromthem any evidence that the claim or lien has been satisfied in full… If such evidence is not forthcoming or fails to resolve theclaim in full without payment by defendant, defendant may byregular mail notify PLAINTIFF'S FIRM to undertake theprincipal response to the matter or to arrange payment or otherresolution. If the U.S. government or its designee including CMSbrings suit, PLAINTIFF'S FIRM will undertake the principaldefense of such matter … PLAINTIFF'S FIRM will be liable todefendant for the amount owed or paid by such defendant to theUnited States Government … for the allegedly unsatisfiedMedicare claim or lien plus all attorney fees and out of pocketexpenses reasonably necessary …

(3) If defendant receives a claim for any unsatisfied Medicare claim… defendant will notify PLAINTIFF'S FIRM … and request fromthem any evidence that the claim or lien has been satisfied in full… If such evidence is not forthcoming or fails to resolve theclaim in full without payment by defendant, defendant may byregular mail notify PLAINTIFF'S FIRM to undertake theprincipal response to the matter or to arrange payment or otherresolution. If the U.S. government or its designee including CMSbrings suit, PLAINTIFF'S FIRM will undertake the principaldefense of such matter … PLAINTIFF'S FIRM will be liable todefendant for the amount owed or paid by such defendant to theUnited States Government … for the allegedly unsatisfiedMedicare claim or lien plus all attorney fees and out of pocketexpenses reasonably necessary …

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Settlement LanguageBut consider

Many plaintiff ’s firms will refuse an indemnification provision. Somestates have ruled finding that a plaintiff ’s attorney cannot agree toindemnify an opposing party for unpaid liens.

Illinois Adv. Op. 06-10 (2006).

But consider

Many plaintiff ’s firms will refuse an indemnification provision. Somestates have ruled finding that a plaintiff ’s attorney cannot agree toindemnify an opposing party for unpaid liens.

Illinois Adv. Op. 06-10 (2006).

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Other settlement optionsMedicare has acknowledged that it can be a joint payee on settlementchecks. The main issue with such a solution is that it puts the burden onthe plaintiff to contest non-suit related charges and it will inevitably delaypayment to the plaintiff, especially in cases where significant futuremedical costs are anticipated. Moreover, drafting a check in such amanner does not absolve a RRE from further following up to ensure thatMedicare is reimbursed.

Medicare has acknowledged that it can be a joint payee on settlementchecks. The main issue with such a solution is that it puts the burden onthe plaintiff to contest non-suit related charges and it will inevitably delaypayment to the plaintiff, especially in cases where significant futuremedical costs are anticipated. Moreover, drafting a check in such amanner does not absolve a RRE from further following up to ensure thatMedicare is reimbursed.

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Other settlement optionsTomlinson v. Landers, 2009 WL 1117399 (M.D.Fla.)

In Tomlinson the defendant included Medicare on the settlement check.The plaintiff returned the check and requested that Medicare not beincluded on the check, promising instead that it would hold thedefendant carrier harmless for any Medicare liens. The court found thatincluding Medicare on the settlement check was not required under therules, and further held that due to the disagreement between the partiesthat the settlement was invalid as the parties never had a meeting of theminds. Tomlinson does not stand for the proposition that Medicarecannot be included on the check when both parties are in agreement.

Tomlinson v. Landers, 2009 WL 1117399 (M.D.Fla.)

In Tomlinson the defendant included Medicare on the settlement check.The plaintiff returned the check and requested that Medicare not beincluded on the check, promising instead that it would hold thedefendant carrier harmless for any Medicare liens. The court found thatincluding Medicare on the settlement check was not required under therules, and further held that due to the disagreement between the partiesthat the settlement was invalid as the parties never had a meeting of theminds. Tomlinson does not stand for the proposition that Medicarecannot be included on the check when both parties are in agreement.

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Settlement ConsiderationsIn the case of a joint and several settlement, where eachdefendant technically is responsible for the wholesettlement, each entity must report the entiresettlement, judgment, award or other payment.

If each defendant enters into a separate settlement,they are each responsible for reporting the separatesettlement, judgment, award or other payment.

See http://www.cms.gov/MandatoryInsRep/Downloads/Jan2810NGHPTranscript.pdf, pg. 20

In the case of a joint and several settlement, where eachdefendant technically is responsible for the wholesettlement, each entity must report the entiresettlement, judgment, award or other payment.

If each defendant enters into a separate settlement,they are each responsible for reporting the separatesettlement, judgment, award or other payment.

See http://www.cms.gov/MandatoryInsRep/Downloads/Jan2810NGHPTranscript.pdf, pg. 20

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Settlement Considerations

What about cases wherein a discounted settlement doesnot allow for reimbursement of Medicare due toquestionable liability?

“Waiver of Rights. The Secretary may waive (in whole orin part) the provisions of this subparagraph in the caseof an individual claim if the Secretary determines thatthe waiver is in the best interests of the programestablished under this title.” 42 USC Secs. 1395 et seq.

What about cases wherein a discounted settlement doesnot allow for reimbursement of Medicare due toquestionable liability?

“Waiver of Rights. The Secretary may waive (in whole orin part) the provisions of this subparagraph in the caseof an individual claim if the Secretary determines thatthe waiver is in the best interests of the programestablished under this title.” 42 USC Secs. 1395 et seq.

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Negotiating Settlement with theCMSConditional Payment Estimate

We are writing to advise you that Medicare has identified aclaim or number of claims for which you have primarypayment responsibility and Medicare has made primarypayment. The Medicare Secondary Payer provisions of thestatute, 42 CFR 1395y(b)(2), precludes Medicare from payingfor a beneficiary’s medical expenses when payment “has beenmade or can reasonably be expected to be made … under no-fault insurance”.

Conditional Payment Estimate

We are writing to advise you that Medicare has identified aclaim or number of claims for which you have primarypayment responsibility and Medicare has made primarypayment. The Medicare Secondary Payer provisions of thestatute, 42 CFR 1395y(b)(2), precludes Medicare from payingfor a beneficiary’s medical expenses when payment “has beenmade or can reasonably be expected to be made … under no-fault insurance”.

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Negotiating Settlement with theCMSHowever, Medicare may pay for a beneficiary’s coveredmedical expenses conditioned on reimbursement toMedicare from proceeds received pursuant to a thirdparty liability settlement, award, judgment, recovery orfrom any entity responsible for making primarypayment. Medicare must recover these payments fromthe entity responsible for payment or when payment hasbeen made from the entity/individual who has receivedpayment for these claims.

However, Medicare may pay for a beneficiary’s coveredmedical expenses conditioned on reimbursement toMedicare from proceeds received pursuant to a thirdparty liability settlement, award, judgment, recovery orfrom any entity responsible for making primarypayment. Medicare must recover these payments fromthe entity responsible for payment or when payment hasbeen made from the entity/individual who has receivedpayment for these claims.

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Negotiating Settlement with theCMSEnclosed is an itemization of conditional paymentsmade by Medicare on behalf of the Medicare beneficiaryreferenced above. Currently, Medicare has paid _______in conditional payments related to your claim.

Enclosed is an itemization of conditional paymentsmade by Medicare on behalf of the Medicare beneficiaryreferenced above. Currently, Medicare has paid _______in conditional payments related to your claim.

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Negotiating Settlement with theCMSFinal Demand Letter

We are writing to you because we recently learned thatyou have made a liability claim relating to an illness,injury, or incident occurring on or about _____ andobtained a recovery. We have determined that you arerequired to repay the Medicare program _______ for thecost of medical care it paid relating to your liabilityrecovery. (The term “recovery” includes a settlement,judgment, award or any other type of recovery.

Final Demand Letter

We are writing to you because we recently learned thatyou have made a liability claim relating to an illness,injury, or incident occurring on or about _____ andobtained a recovery. We have determined that you arerequired to repay the Medicare program _______ for thecost of medical care it paid relating to your liabilityrecovery. (The term “recovery” includes a settlement,judgment, award or any other type of recovery.

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Negotiating Settlement with theCM Right to Request a Waiver - you have the right to

request that the Medicare program waive recovery ofthe amount you owe in full or in part. Your right torequest a waiver is separate from your right to appealour determination, and you may request both a waiverand an appeal at the same time. The Medicareprogram may waive recovery of the amount you owe ifyou can show that you meet both of the followingconditions:

Right to Request a Waiver - you have the right torequest that the Medicare program waive recovery ofthe amount you owe in full or in part. Your right torequest a waiver is separate from your right to appealour determination, and you may request both a waiverand an appeal at the same time. The Medicareprogram may waive recovery of the amount you owe ifyou can show that you meet both of the followingconditions:

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Negotiating Settlement with theCMS1. This overpayment (for purposes of requesting

waiver of recovery, the amount you owe is consideredan overpayment) was not your fault, because theinformation you gave us with your claims forMedicare benefits was correct and complete as far asyou knew; and when the Medicare payment was made,you thought that it was the right payment; AND

2. Paying back this money would cause financialhardship or would be unfair for some otherreason.

1. This overpayment (for purposes of requestingwaiver of recovery, the amount you owe is consideredan overpayment) was not your fault, because theinformation you gave us with your claims forMedicare benefits was correct and complete as far asyou knew; and when the Medicare payment was made,you thought that it was the right payment; AND

2. Paying back this money would cause financialhardship or would be unfair for some otherreason.

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Negotiating Settlement with theCMSRight to Appeal - You also have the right to appeal ourdetermination if you disagree that you owe Medicare asexplained in Part I of this letter, of if you disagree withthe amount that you owe Medicare ______ as explainedin Part II of this letter. To file an appeal, you should sendus a letter explaining why you think the amount you oweMedicare is incorrect and/or any reason(s) why youdisagree with our determination.

120 days from receipt of letter.

Right to Appeal - You also have the right to appeal ourdetermination if you disagree that you owe Medicare asexplained in Part I of this letter, of if you disagree withthe amount that you owe Medicare ______ as explainedin Part II of this letter. To file an appeal, you should sendus a letter explaining why you think the amount you oweMedicare is incorrect and/or any reason(s) why youdisagree with our determination.

120 days from receipt of letter.

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Negotiating Settlement with theCMS

Counsel should be familiar with whether their request isfor a complete waiver, a compromise allocation or a fullcommutation before contacting any Medicarerepresentative. In the case of a compromise request,counsel should be familiar with 42 CFR § 411.47 whichgoverns compromise settlements in workers’compensation cases and is currently the best toolavailable for an argument reducing a Medicare paymentin a liability case. That section states:

Counsel should be familiar with whether their request isfor a complete waiver, a compromise allocation or a fullcommutation before contacting any Medicarerepresentative. In the case of a compromise request,counsel should be familiar with 42 CFR § 411.47 whichgoverns compromise settlements in workers’compensation cases and is currently the best toolavailable for an argument reducing a Medicare paymentin a liability case. That section states:

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Negotiating Settlement with theCMS42 CFR § 411.47 proposes a ratio analysis.

If a settlement does not apportion the sum granted, the portion tobe considered as payment for medical expenses is computed asfollows:

Determine the ratio of the amount awarded to the total amountthat would have been payable … if the claim had not beencompromised.

Multiply that ratio by the total medical expenses incurred as aresult of the injury or disease up to the date of the settlement.

42 CFR § 411.47 proposes a ratio analysis.

If a settlement does not apportion the sum granted, the portion tobe considered as payment for medical expenses is computed asfollows:

Determine the ratio of the amount awarded to the total amountthat would have been payable … if the claim had not beencompromised.

Multiply that ratio by the total medical expenses incurred as aresult of the injury or disease up to the date of the settlement.

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Negotiating Settlement with theCMSBut see Hadden v. United States,

In Hadden the plaintiff ’s medical bills totaled over$82,000. The defendant settled the case for $125,000.After deducting attorneys’ fees, Medicare demandedover $62,000.

Hadden paid under protest noting that the settlingdefendant was only 10% at fault, and therefore arguingwas only responsible for about $8,000 of his medicalexpenses.

But see Hadden v. United States,

In Hadden the plaintiff ’s medical bills totaled over$82,000. The defendant settled the case for $125,000.After deducting attorneys’ fees, Medicare demandedover $62,000.

Hadden paid under protest noting that the settlingdefendant was only 10% at fault, and therefore arguingwas only responsible for about $8,000 of his medicalexpenses.

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Negotiating Settlement with theCMSThe court applied the Chevron standard in analyzing theMedicare related statutes. Chevron U.S.A., Inc. v.National Resources Defense Counsel, Inc., 467 U.S. 837,842-43 (1984).

IF Congress “has directly spoken to the precise questionat issue” in the text of the statute, the court gives effectto Congress’s answer without regard to any divergentanswers offered by the agency or anyone else.

The court applied the Chevron standard in analyzing theMedicare related statutes. Chevron U.S.A., Inc. v.National Resources Defense Counsel, Inc., 467 U.S. 837,842-43 (1984).

IF Congress “has directly spoken to the precise questionat issue” in the text of the statute, the court gives effectto Congress’s answer without regard to any divergentanswers offered by the agency or anyone else.

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But, IF “the statute is silent or ambiguous with respect tothe specific issue, the question for the court is whetherthe agency’s answer is based on a permissibleconstruction of the statute.”

But, IF “the statute is silent or ambiguous with respect tothe specific issue, the question for the court is whetherthe agency’s answer is based on a permissibleconstruction of the statute.”

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The CMS has interpreted the statute finding thatMedicare is “entitled to a full reimbursement ofconditional Medicare payments when a beneficiaryreceives a discounted settlement from a third party.Zinman v. Shalala, 67 F.3d 841, 845 (9th Cir. 1995).

The CMS has interpreted the statute finding thatMedicare is “entitled to a full reimbursement ofconditional Medicare payments when a beneficiaryreceives a discounted settlement from a third party.Zinman v. Shalala, 67 F.3d 841, 845 (9th Cir. 1995).

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The scope of a payer’s responsibility for a beneficiary’smedical expenses – is defined by the scope of the claimagainst the payer, regardless of whether a compromisehas been reached or if the payer never admits liability.

“And thus a beneficiary cannot tell a third party that it isresponsible for all of his medical expenses, on the onehand, and later tell Medicare that the same party wasresponsible for only 10% of them, on the other.”

The scope of a payer’s responsibility for a beneficiary’smedical expenses – is defined by the scope of the claimagainst the payer, regardless of whether a compromisehas been reached or if the payer never admits liability.

“And thus a beneficiary cannot tell a third party that it isresponsible for all of his medical expenses, on the onehand, and later tell Medicare that the same party wasresponsible for only 10% of them, on the other.”

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Negotiating Settlement with theCMSSimilar language governs the plaintiff ’s counsel’srecovery under 42 C.F.R. Sec. 411.37(c)

Determine the ratio of the procurement costs to the totaljudgment or settlement payment.

Apply the ratio to the Medicare payment. The product isthe Medicare share of procurement costs.

Similar language governs the plaintiff ’s counsel’srecovery under 42 C.F.R. Sec. 411.37(c)

Determine the ratio of the procurement costs to the totaljudgment or settlement payment.

Apply the ratio to the Medicare payment. The product isthe Medicare share of procurement costs.

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Iowa Supreme Court Attorney Disciplinary Board v.Silich, 972 N.W.2d 181 (Dec. 2015).

In one recent case, an attorney’s delay in resolving aMedicare subrogation lien on a tort settlement violatedrules of professional conduct relating to due diligence,client communication, and expediting litigation.

The attorney was suspended for 30 days.

Iowa Supreme Court Attorney Disciplinary Board v.Silich, 972 N.W.2d 181 (Dec. 2015).

In one recent case, an attorney’s delay in resolving aMedicare subrogation lien on a tort settlement violatedrules of professional conduct relating to due diligence,client communication, and expediting litigation.

The attorney was suspended for 30 days.

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Medicare Part C IssuesSeveral state courts are grappling with whether MedicareAdvantage Organizations (Part C organizations), orprivate companies acting as Medicare insurers have thesame rights as Medicare in recovering under theMedicare “superlien” rather than under state lienprocedures. Several courts have held that MAOs havethe same rights under the Medicare statutes to enforce asuperlien.

Several state courts are grappling with whether MedicareAdvantage Organizations (Part C organizations), orprivate companies acting as Medicare insurers have thesame rights as Medicare in recovering under theMedicare “superlien” rather than under state lienprocedures. Several courts have held that MAOs havethe same rights under the Medicare statutes to enforce asuperlien.

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Medicare Part C IssuesNotwithstanding any other provision of law [an MAO] may (in thecase of the provision of items and services to an individual under[an MA] plan under the circumstances in which payment underthis subchapter is made secondary pursuant to section 1395y(b)(2)of this title) charge or authorize the provider of such services tocharge, in accordance with the changes allowed under a law, plan,or policy described in such section-(A) The insurance carrier, employer, or other entity which under

such law, plan, or policy is to pay for the provision of suchservices, or

(B) Such individual to the extent that the individual has been paidunder such law, plan, or policy for such services.

42 USC Section 1395w-22(a)(4)

Notwithstanding any other provision of law [an MAO] may (in thecase of the provision of items and services to an individual under[an MA] plan under the circumstances in which payment underthis subchapter is made secondary pursuant to section 1395y(b)(2)of this title) charge or authorize the provider of such services tocharge, in accordance with the changes allowed under a law, plan,or policy described in such section-(A) The insurance carrier, employer, or other entity which under

such law, plan, or policy is to pay for the provision of suchservices, or

(B) Such individual to the extent that the individual has been paidunder such law, plan, or policy for such services.

42 USC Section 1395w-22(a)(4)

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Medicare Part C IssuesMSP rules and State laws. Consistent with Section 422.402concerning the Federal preemption of State law, the rulesestablished under this section supersede any State laws,regulations, contract requirements, or other standards thatwould otherwise apply to MA plans. A State cannot take awayan MA organization’s right under Federal law and the MSPregulations to bill, or to authorize providers and suppliers tobill, for services for which Medicare is not the primary payer.The MA organization will exercise the same rights to recoverfrom a primary plan, entity, or individual that the Secretaryexercises under the MSP regulations in subparts B through Dof part 411 of this chapter.42 CFR Section 422.108(f)

MSP rules and State laws. Consistent with Section 422.402concerning the Federal preemption of State law, the rulesestablished under this section supersede any State laws,regulations, contract requirements, or other standards thatwould otherwise apply to MA plans. A State cannot take awayan MA organization’s right under Federal law and the MSPregulations to bill, or to authorize providers and suppliers tobill, for services for which Medicare is not the primary payer.The MA organization will exercise the same rights to recoverfrom a primary plan, entity, or individual that the Secretaryexercises under the MSP regulations in subparts B through Dof part 411 of this chapter.42 CFR Section 422.108(f)

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Jeremy BurtonLipe Lyons Murphy Nahrstadt & Pontikis Ltd.

230 West Monroe Street, Suite 2260Chicago, IL 606006

(312) [email protected]

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