GENEX Services, Inc. presentation to

Barbara Silvas, RN, BSN,

CNLCP, MSCC, LNC

October 16, 2013

Medicare Challenges

Presented to:

KSIA Conference

© 2013 GENEX Services, Inc. 2

Agenda

Emerging Trends

Protecting Medicare

Medicare Set-Aside

SMART Act

Controlling Costs

Government Resources


Emerging Trends

Medicare Trends


Emerging Trends

1965 Medicare Enacted

1980 Medicare Secondary Payer (MSP) Statute Enacted

2003 Medicare Modernization Act

2007 Section 111 of the Medicare, Medicaid,

and SCHIP Extension Act (MMSEA)

2011 - 2012 Mandatory Reporting

Cited Work: Data 360. Website:

http://www.data360.org Accessed 09/06/11

2001 – Multiple CMS Memos on MSAs

2013, Jan. 10 – SMART Act

Public Law No: 112-242

http://www.data360.org/

http://www.data360.org/


Emerging Trends

0

50

100

150

200

250 Bi

llion

s of

Dol

lars

Medicare Covered Services 2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

Cited Work: Medicare Baseline – Congressional Budget Office.

March 2012 Website: http://www.cbo.gov Accessed: 08/21/12

http://www.cbo.gov/


Emerging Trends

“Nationwide, we will see more than

1.8 million people turn 65 each

year beginning in 2011. This

translates into more than 5,000 a

day, which is a substantial number.”

Cited Work: Aging Baby Boomers Will Have Significant Impact

on Medicare Enrollment. Oct 16, 2008 Source: Richard Rathge.

Website: http://www.ag.ndsu.edu Accessed: 09/06/11

http://www.ag.ndsu.edu/


Emerging Trends

Government Accountability Office (GAO)

In fiscal year 2010, the Centers for Medicare

& Medicaid Services (CMS)--the agency that

administers Medicare and Medicaid—

estimated that these programs made a total

of over $70 billion in improper payments.

*It is based on 16 GAO products issued from April 2004 through June

2010 using a variety of methodologies, such as analyses of Medicare or

Medicaid claims, review of relevant policies and procedures, and

interviews with officials.

Cited Work:. Government Accountability Office.

Website: http://www.gao.gov Accessed: 05/03/11

http://www.gao.gov/

http://www.gao.gov/

© 2013 GENEX Services, Inc.

Protecting Medicare


Protecting Medicare


Protecting Medicare

Centers for Medicare & Medicaid Services

(CMS) Provides Health Coverage

for 100 Million People...

... through Medicare, Medicaid, and the Children's Health Insurance Program.

And with health insurance reforms and health care exchanges, we are improving health

care and ensuring coverage for all Americans.

Cited Work: Home | Centers for Medicare and Medicaid Services.

Website: http://www.cms.gov Accessed: 08/24/12

http://www.cms.gov/

http://www.cms.gov/


Protecting Medicare

Centers for Medicare and Medicaid Services

(CMS)

Coordinator

Of Benefits

Contractor

(COBC)

Medicare

Secondary Payer

Recovery

Contractor

(MSPRC)


Protecting Medicare

CMS CMS memorandums regarding MSAs

Responsible for MSA Submissions

MSA review process – Regional Offices and Workers Compensation Review Center

(WCRC)

Final MSA Determination

Final settlement papers are submitted to CMS

COBC Responsible for Mandatory Reporting

Data Collection from RREs for Mandatory Reporting

Intake for claim reporting

MSP Responsible for Conditional Liens

Medicare Set-Aside Reconciliation

Medicare Set-Aside Trust Fund Accounts

Each of these have multiple

other responsibilities. In the

MSA arena, these are the areas

of their primary functions.


Medicare Set-Aside


Medicare Set-Aside

MSA allocation determines future

medical/pharmacy exposure for Medicare

Documents past, present medical/pharmacy

treatment

May include a Rated Age

The Medicare Set-Aside allocation is a

component of the medical settlement of a

file


Medicare Set-Aside

Under the umbrella of Medicare Set-Aside:

Social Security, Medicare Verification

Status

Medicare Set-Aside

Submission

Conditional Lien


Medicare Set-Aside

Social Security, Medicare Verification Status

Identifies Medicare Beneficiaries

Identifies Social Security Disability Insurance

Recipients

Identifies Medicaid Recipients

CMS Working Thresholds/Medicare Set-Aside

Medicare Beneficiary at time of Settlement >

$25,000

Anticipated Medicare Beneficiary within 30

months of Settlement > $250,000


CMS Trends & Patterns

TENS Unit/Supplies – Medicare will not cover for

chronic low back as of June 2012. Will cover for

other diagnosis/diagnoses.

Benzodiazepines and Barbiturates – Medicare

begins coverage January 2013 for:

Epilepsy

Cancer

Chronic mental health disorders

Centers for Medicare and Medicaid Services. CMS.Gov. Website:

http://www.cms.gov Accessed: 06/12/12

Centers for Medicare and Medicaid Services. CMS.Gov. 08/14/2012 Draft 2012 Current Topics

Page 59. Website: http://www.cms.gov Accessed 08/20/12

http://www.cms.gov/

http://www.cms.gov/

http://www.cms.gov/



Part D Coverage in Long‐Term Care Facilities

Beneficiaries who live in LTC facilities

Part D‐covered brand‐name drugs must be

dispensed in increments of 14‐days or less

e.g., instead of 30‐day supply

Some exceptions (e.g., antibiotics)

Intended to reduce amount of unused drugs

Cost‐sharing can’t be more than a 30 day fill

Effective January 1, 2013

Centers for Medicare and Medicaid Services. CMS.Gov. 08/14/2012 Draft 2012 Current Topics

Page 60. Website: http://www.cms.gov Accessed 08/20/12



Seed/Initial Deposit Amounts

Two years of annual payments

First surgery or replacement which may include:

Spinal Cord Stimulator or Pain Pump trial

First Spinal Cord Stimulator or replacement

First Pain Pump or replacement

Facet Blocks

Epidural Steroid Injections

Prosthesis replacement


MSA Submission Requirements

Submitter Letter or Other Summary Documentation

Consent Form

Rated Age Information or Life Expectancy

Life Care Plan

Settlement Agreement or Proposed or Court Order

Set-Aside Administrator or Copy of Agreement

Medical Records

Payment History

Future Treatment Plan

Supplemental or Additional Information


What is a Conditional Payment?

A conditional payment is a payment that Medicare

makes for services where another payer may be

responsible

This conditional payment is made so that the

beneficiary won’t have to use their own money to pay

the bill

The payment is “conditional” because it must be

repaid to Medicare when a settlement, judgment,

award or other payment is secured

Medicare Secondary Payer Recovery Contractor (MSPRC).

What to Know About Conditional Payment Letters (CPL).

Website: http://www.msprc.info Accessed: 08/24/12

http://www.msprc.info/



SMART Act


SMART Act

H.R. 1845

12/19/2012 – Passed House

12/21/2012 – Passed Senate

Signed by President Obama

January 10, 2013

Public Law No: 112-242

Medicare IVIG Access and Strengthening Medicare

and Repaying Taxpayers Act of 2012

Library of Congress. THOMAS Home. Website:

http://thomas.loc.gov Accessed: 01/24/13

http://thomas.loc.gov/




SMART Act

“Passage of legislation produces wins for Medicare

beneficiaries, the Medicare Trust Fund and businesses

resolving claims. Coalition applauds Representatives

Tim Murphy (R-PA) and Ron Kind (D-WI), and Senators

Ron Wyden (D-OR) and Rob Portman (R-OH) for their

bipartisan leadership.”

Interested in joining MARC?

Call Roy Franco at 716-877-4677 Extension 137

SMART Act. MARC Advocacy Recovery Coalition. Website:

http://www.marccoalition.com Accessed: 01/24/13.

Medicare Advocacy Recovery Coalition

(MARC)


SMART Act

SEC. 201

Know final conditional lien amount prior to settlement

Alternative method for obtaining conditional lien amount

Not mandatory

Protected period

SEC. 202

Reporting threshold is statutorily based

Liability insurance (including self-insured) only

Will be determined annually

The SMART Act Delivers


SMART Act

SEC. 203

Penalty modifications

Increases flexibility

Modifies language from “shall” to “may”

SEC. 204

Phasing out of the use of social security and health claim

insurance numbers

Social security and health claim insurance numbers

permitted but not required

SEC. 205

Three (3) year statute of limitations under the MSP Act

The SMART Act Delivers


SMART Act

(vii) USE OF WEBSITE TO DETERMINE FINAL CONDITIONAL REIMBURSEMENT AMOUNT.—

(I) NOTICE TO SECRETARY OF EXPECTED DATE OF A SETTLEMENT, JUDGMENT, ETC

(II) SECRETARIAL PROVIDING ACCESS TO CLAIMS INFORMATION THROUGH A WEBSITE

(III) USE OF TIMELY WEB DOWNLOAD AS BASIS FOR FINAL CONDITIONAL AMOUNT-

Protected Period (subclause V)

(IV) RESOLUTION OF DISCREPANCIES

(V) PROTECTED PERIOD

(VI) EFFECTIVE DATE

(VII) WEBSITE INCLUDING SUCCESSOR TECHNOLOGY

(viii) RIGHT OF APPEAL FOR SECONDARY PAYER DETERMINATIONS RELATING TO LIABILITY

INSURANCE (INCLUDING SELF-INSURANCE), NO FAULT INSURANCE, AND WORKERS’

COMPENSATION LAWS AND PLANS.—

Section 201 Effective Date “not later than 9 months after the

date of the enactment of this clause”

Cited Work: Congressional Record – House. December 19, 2012.

H7301. Website: http://primaryimmune.org Accessed: 01/28/13

http://primaryimmune.org/


SMART Act

Section 201 (I)

Notice to Secretary

Settlement , judgment, award or other payment is

reasonably expected within 120 days

Section 201 (II)

Access shall be provided to

an individual,

representative, or plan

through a website that

requires a password to gain

access to the information.

The Secretary shall update

the information on claims

and payments on such

website in as timely a

manner as possible but not

later than 15 days after the

date that payment is made.


SMART Act

Section 201 (II)

Information shall be as complete as possible to

include demographics involved with the conditional

lien

Section 201 (III)

Within

Protected Period

Subclause V

…then the last statement of reimbursement

amount that is downloaded during such period

and within 3 business days before the date of

the settlement, judgment, award, or other

payment shall constitute the final conditional

amount subject to recovery…


SMART Act

Section 201 (IV)

Resolution of Discrepancies – individual or authorized representative

provides explanation of discrepancy and proposal to resolve

Secretary shall

determine within 11

business days to

include or remove

discrepancies

Secretary doesn’t

make determination

within 11 business

days – the proposed

resolution accepted

The resolution of disputes is not

an appeals process – no

administrative or judicial review

of Secretary’s determination


SMART Act

Section 201 (V)

Notice to Secretary

Settlement, judgment,

award within 120 days

Protective Period Starts

Secretarial response period: 65

days, may be extended 30 days

shall be extended. In exceptional

circumstances (not more than 1%

would qualify) for the Secretary to

extend if a failure in claims and

posting system as defined in

regulation

The term ‘website’ includes any successor technology.

Section 201 (VI)

The Secretary shall promulgate final

regulations to carry out this clause

not later than 9 months after the date

of the enactment of this clause Section 201 (VII)

Effective Date


SMART Act

Section 201 (viii)

The Secretary shall promulgate regulations

establishing a right of appeal and appeals

process,

Right To Appeal – Appeals can come from:

applicable plan involved

attorney

agent

third party administrator on behalf of

such plan


SMART Act

Section 202 Effective Date “shall apply to years beginning with 2014”

Not later than November 15 before each year, the

Secretary shall calculate and publish a single

threshold amount, submitting to Congress a report on

the single threshold amount.

Identify

Cost Cost

Divided Level of

Conditional

Payments

Secretary

Matches Results in

Established

Threshold

Thresholds: Mandatory Reporting and Conditional Lien Reimbursement

**this replaces the information in the UserGuideVer3.4Ch3Policy “If the most recent TPOC Date is on or after October 1,

2014, and the cumulative TPOC Amount is greater than $300, the TPOC(s) must be reported no later than the end of the

RRE’s submission timeframe in the quarter beginning January 1, 2015.” This new threshold should supersede the

UserGuideVer3.4Ch3Policy – this will be a permanent threshold with a varying dollar amount each year beginning 2015.


SMART Act

Section 203 Effective Date - Final rules should be issued 180 days after

enactment.

‘shall be subject’ changed to ‘may be subject’ to a

civil money penalty of up to $1,000 for each day of

noncompliance with respect to each claimant.

• Notice in Federal Register soliciting proposals

• Accepted for 60 days

• Will specify what will and will not be sanctioned, including not

imposing sanctions for good faith efforts to identify a beneficiary

• Consultation with the Attorney General

• Publish proposals in Federal Register

• 60-day comment period

• Secretary to issue final rules specifying such practices – what will

and what will not be sanctioned


SMART Act

Section 204 Effective Date - not later than 18 months after enactment; the deadline

can be extended by one or more periods up to 1 year (with specific notifications of the

extension/progress being made/anticipated implementation date)

…the Secretary shall modify the

reporting requirements – social

security account number or

health identification claim

numbers are not required.


SMART Act

Section 205 Effective Date: 6 months after the date of enactment of this Act

An action may not be brought by the United States under this

clause with respect to payment owed unless the complaint is filed

not later than 3 years after the date of the receipt of notice of a

settlement, judgment, award, or other payment made pursuant to

paragraph (8) relating to such payment owed.

STATUTE OF LIMITATIONS


SMART Act

Report to Secretary file is expected to be settled within 120 days

Request conditional lien amount; submit signed consent

Secretary has 65 days to post on website; can be extended 30 days

Secretary update information not later than 15 days after payment made

Discrepancy resolution – Secretary has 11 business days after receipt of

documentation to remove items or not to remove giving good cause and

alternate resolution

The conditional lien amount posted on the website 3 business days prior to

the settlement, etc., constitutes the final conditional payment amount

It is imperative all parties involved in the settlement are working together

and work within the “protected period”

Work in progress with some of these new regulations


SMART Act Implementation Update

9/20/13 CMS issued proposed rules related to SMART Act

CMS plans to implement multi-factor authentication system

Permits authorized attorney, representative or authorized plan to view

specific claim data

Increase functionality of existing Web portal

permit users to notify CMS of impending settlement

obtain final conditional payment summary

file dispute as to the relatedness of claims

expect CMS to address disputed discrepancies within 11 business

days of receipt of dispute

CMS anticipates implementation no later than January 1, 2016


Controlling Costs


Controlling Costs

Medicare beneficiary? Reasonable expectation?

Medicare Set-Aside – future

Settlement thresholds for CMS review

Conditional payment information

Consider Medicare’s interest

Penalties


No matter what the settlement amount is….

Settlement money for future Medicare covered expenses

Document claimant’s understanding…

Determination of Medicare covered expenses

How you protected Medicare…

Controlling Costs


PTP – future medical and prescription

PTP - future surgeries?

Conflicting treatment plans? Clarify…

Change in treatments -> medical records

Be proactive on your files

Be proactive in obtaining conditional payment

Controlling Costs


Document your file

In writing

Investigate conditional payments

Document -> settlement papers -> future $$$

Obtain Medicare Set-Aside

CMS approved MSA, if applicable

How to Protect the Interest of Medicare





Learn more about Medicare Set-Asides at

http://www.cms.gov/WorkersCompAgencyServices.asp

Learn more about Medicare Secondary Payer at

http://www.msprc.info

Learn more about Mandatory Reporting at

http://www.cms.gov/MandatoryInsRep.asp

http://www.cms.gov/WorkersCompAgencyServices.asp


http://www.cms.gov/MandatoryInsRep.asp


Q & A

To learn more, contact:

GENEX Medicare Set-Aside Services

(877) 674-5175

[email protected]

www.genexservices.com

http://www.genexmdn.com/


Q & A

Brittney Parrish

Area Sales Manager

Office: 502-893-9136 x7565

Cell: 502-640-4380

Email: [email protected]

mailto:[email protected]