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Birmingham Bar Association Bulletin - Fall 2014

Medicare Law ment amount to Medicare for review. The beneficiary must also demonstrate that treatment has been completed and no further treatment is expected - this must be demonstrated through either (1) a written physician attestation or (2) a written certification provided by the beneficiary that (a) no medical treatment related to his/her case has occurred for at least 90 days prior to submitting the self-calculated final conditional payment amount to Medicare and (b) he/she expects no further care related to his/her case.   In order to take advantage of this option, the beneficiary is to mark each claim on the Payment Summary Form that accompanied the Conditional Payment Letter with a “Y” if related and with an “N” if not related. The beneficiary is required to provide an explanation for why the “N” claims are not related. Any additional claims for related care that have arisen after the issuance of the Conditional Payment Letter are also to be added. The beneficiary then completes the Self-Calculated Conditional Payment Amount model language document, which can be found in the attorney tool kit at http://go.cms.gov/attorney. Insurers are being directed to http://go.cms. gov/insurer. Medicare is supposed to let the beneficiary know within 60 days whether the MSPRC agrees or disagrees with the Self-Calculated Conditional Payment Amount. Online Portal C. CMS has recently established an on-line portal, which allows individuals other than Medicare beneficiaries themselves to access reimbursement-related information. For example, through the portal, attorneys and carriers are able to download executed Consent to Release forms, obtain conditional payment amounts and request updated lien amounts and final demand letters. In order to access the portal, the following information is required: •  beneficiary’s date of birth; •  social security number or Medicare ID; •  Medicare’s 15-number case ID (which can be found on any correspondence from CMS once the claim has been reported). In order to request updated conditional payment totals and final demand letters, there must be a Consent to Release on file with CMS. This portal is very helpful in that it significantly shortens the time period in which we can obtain Medicare’s lien information. CMS has also instituted an automated self-service line that can be accessed through the main number, 1-866- 677-7220. The self-service line only provides the last reported conditional payment information and does not allow for requests or updates. As part of the SMART Act, set forth in more detail below, CMS has also released an interim final rule as of mid- October 2013 that involves developing a multifactor authentication solution to permit multiple users to access information on the portal and will update the online portal to allow users to notify CMS that a case is nearing settlement, obtain time and date stamped final conditional payment summary forms and amounts prior to settlement, and ensure that disputes regarding claims included in the final conditional payment amount are resolved within 11 days of CMS’s receipt of the dispute through the portal. Health Insurance Form D. One other interesting development concerns correspondence recently sent by CMS to a Medicare beneficiary that reads as follows: “Medicare’s records show that you have health insurance through a Liability Case. So that your Medicare claims may be processed correctly, please give us a brief description of the type of injury or illness you sustained, or if you have the actual diagnosis code(s) for your injury/ condition, please supply them here and return this form in the enclosed return envelope.” (emphasis added). The danger with this form is that it can be inferred that any treatment that is coded by the medical provider in conjunction with what the claimant/plaintiff lists as related will most likely not be covered by Medicare. In other words, Medicare is categorizing future medical expenses as “health insurance” for which a liability carrier, not Medicare, is responsible. Assuming similar letters are to be sent on all cases involving future medical treatment, it will be critical to carefully word and/or code the related treatment so that unrelated treatment is not lumped in. E. SMART Act In late December 2012, the United States House and Senate passed the Strengthening Medicare and Repaying Taxpayers Act (SMART Act), and President Obama signed the bill into law on January 10, 2013. The purpose of the SMART Act is to make the new reporting and reimbursement requirements more efficient by decreasing bureaucratic delays in the process. The Act addresses obtaining the Medicare lien amount, creating an annual threshold, reconsidering the civil penalties for non-compliance, and statute of limitations. 24 Birmingham Bar Association


Birmingham Bar Association Bulletin - Fall 2014
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