Category Archives: Medicare

joint replacement, Medicare

Need Joint Replacement and on Medicare? Better Not Be Sick.

Having a lung ailment may make it more difficult to obtain coverage for joint replacement.

Today’s post comes from guest author Charlie Domer, from The Domer Law Firm.

A new Medicare rule that took effect April 1, 2016 retools Medicare payments for hip and knee replacements.  Patients with serious medical conditions such as heart disease, obesity, diabetes, and lung ailments may not be able to find an orthopaedic surgeon willing to perform the joint replacement because hospitals face financial incentives to avoid patients with a high risk of complications. 

Hospitals will be given a “target price” for total joint replacements for the patient’s entire care from the hospital stay to outpatient rehabilitation through 90 days after discharge, according to a new rule from the Center for Medicare Services.  If the reimbursement is less than the target price, the hospital may receive an additional payment from Medicare as an incentive for good outcomes.  On the other hand, the hospital may be required to pay back part of their reimbursement that goes above the target.  The rule is intended to control costs on the $7 Billion Medicare spends for hospital care and for almost one-half million beneficiaries who receive a hip or knee replacement each year.  However, since Medicare will pay only one “bundled payment” for the patient’s entire care after total joint replacement surgery, the hospital will be accountable for the quality of care through the incentives and penalties.  The surgeon shares responsibility when a patient is re-admitted to the hospital and receives a “black mark” even when the re-admission has nothing to do with the joint replacement.  An unintended consequence of this payment model may be “cherry picking” of low risk patients.  Patients claiming a work-related connection to joint replacement surgery who have been denied by Medicare may face additional hurdles in obtaining their surgery. 

Stay tuned…

Future Medical Expenses, Medicare, Workers Compensation

Settling a Workers’ Compensation Claim – Future Medicals and Medicare

Today’s post comes from guest author Kristina Brown Thompson, from The Jernigan Law Firm.

Will Medicare cover my future medical expenses for my workers’ compensation injury if I settle my case? Yes, no, maybe…the answer to this question is always a tricky one. In fact, this is one of the most complex questions that will confront an injured worker at the time of settlement.

Most settlements are final. Once you agree, you may have created a binding contract that will have serious financial repercussions for you and your family. It’s best to be prepared ahead of time so you fully understand the potential impact of a settlement. Settlement agreements cannot be set aside except in very rare circumstances. Before settling your case, you should take a full accounting of your future medical expenses and your insurance coverage. In reviewing your medical needs, do not forget to account for over-the-counter medications. These costs add up quickly over time.

If you are already a Medicare beneficiary, it’s quite likely you will need to set aside a portion of your settlement for future medical expenses. Medicare may refuse to pay for medical coverage relating to your injuries unless you’ve allocated some of the settlement funds for future medicals. Determining how much to set-aside is another complicated question and usually an outside company is hired to help assist with this determination.

Furthermore, injured workers must also take into consideration the fact that there are certain medical expenses that Medicare may not cover. For example, when an injured worker needs someone to take care of them. Medicare will not pay for these services so the injured worker would be forced to pay if she failed to negotiate this amount prior to settlement. Also, even when Medicare does help foot the bill, the injured worker will still likely pay the coinsurance amount (typically 20%). In short, be careful and think about future medical expenses.

Legislation, Medicare, Workers Compensation

Making A Difference In Washington – The Medicare Secondary Payer and Workers’ Compensation Settlement Agreement Act

Today’s post comes from guest author Catherine Stanton from Pasternack Tilker Ziegler Walsh Stanton & Romano.

In addition to helping our clients receive the benefits they are entitled to through the courts and other adversarial means, we are prooud to work with our elected officials to produce legislation that will benefit working people. A few days ago, a bill we support, the Medicare Secondary Payer and Workers’ Compensation Settlement Agreement Act, was formally proposed. We encourage you to call and email your representatives and let them know that you support this law.

The press release with additional background follows:

 

Reps. Reichert and Thompson Introduce Bipartisan Medicare Secondary Payer and Workers’ Compensation Settlement Agreement Act

Washington, D.C. – Today, U.S. Reps. Dave Reichert (R-WA) and Mike Thompson (D-CA) introduced the Medicare Secondary Payer and Workers’ Compensation Settlement Agreement Act, H.R. 1982 into the House of Representatives.

The legislation aims to protect injured workers whose workers’ compensation claims overlap with Medicare coverage. Far too often, these claims are subjected to lengthy and cumbersome reviews by the Centers for Medicare and Medicaid Services (CMS) to determine appropriate set-aside amounts to pay for future medical costs in which Medicare may have an interest. The delays associated with this review place unfair burdens upon the injured party.

“This is a common-sense measure to ensure that hard-working Americans are not left in limbo because of inefficient bureaucratic procedures,” said Rep. Reichert. “Injured workers must have the confidence that their heath care claims will be processed in a fair and timely manner. By introducing this bill, Rep. Thompson and I aim to do just that: protect our hard-working citizens by making sure our systems serve them and their families.”

“The last thing injured workers should have to worry about is if needless bureaucracy is going to prevent their medical bills from being paid,” said Thompson. “This bill will make sure hard working families’ medical claims are processed efficiently and quickly, it will reduce bureaucratic headaches for businesses, and it will save taxpayers money. I will continue working with Congressman Reichert to get this bipartisan bill signed into law.”

Background

The Medicare Secondary Payer and Workers’ Compensation Settlement Agreements Act establishes clear and consistent standards for an administrative process that provides reasonable protections for injured workers and Medicare. It would benefit injured workers, employers and insurers by creating a system of certainty, and allows the settlement process to move forward while eliminating millions of dollars in administrative costs that harm workers, employers and insurers.

The legislation has widespread support from groups such as the American Insurance Association, the American Bar Association, the National Council of Self-Insurers, Property Casualty, Insurers Association of America, UWC-Strategic Services and the Workers Injury Law and Advocacy Group (WILG).

Medicare

President Obama signs the SMART Act Into Law

The SMART Act will modify the process through which the Medicare program is reimbursed when another payer (for example, a liability insurer) is responsible for a beneficiary’s medical costs.

As reported by Medivest Benefits Advisors, President Obama signed the Strengthening Medicare and Repaying Taxpayers (Smart) Act into law as part of H.R. 1845, on January 10, 2013. This bill represents one of the most significant changes in the Medicare Secondary Payer (MSP) conditional payment recovery process since the MSP Statue was enacted in 1981.

The SMART bill is the result of over four years of effort from the Medicare Advocacy Recovery (MARC) Coalition, which represents virtually every group of stakeholders impacted by the Medicare Secondary Payer (MSP) statute. The Congressional Budget Office estimated that the SMART Act would save Medicare $45 million from 2013-2022 by making it easier for payers to reimburse Medicare.

The Smart Act amends the Medicare Secondary Payer Statue by adding a new clause at the end of the existing statute that provides for the following:

  • Section 201 – Expedited Repayment, Web Portal and Right of Appeal. This section requires CMS to maintain and make available a timely updated website so settling parties can determine how much is owed to CMS for conditional payments, during the settlement process. It also requires CMS to provide a timely appeals process and to promulgate related regulations, if the settling parties believe there is a discrepancy in the conditional payment statement.
  • Section 202 – Threshold. Establishes that an actuarial single threshold amount be set for exemption from conditional payment reimbursement, where the expected recovery amount is less than the cost to recover.
  • Section 203 – Section 111 Penalties. Makes the $1,000 per day Mandatory Insurer Reporting (MIR) non-reporting penalty prevision discretionary by changing the statutory language from “shall be subject” to “may be subject to”. Also, this section requires CMS to publish formal regulations specifying situations where the penalty will not be imposed due to good faith efforts to comply.
  • Section 204 – Social Security Number. Directs CMS to modify the MIR reporting requirements so that reporting of social security numbers are not required.
  • Section 205 – Statute of Limitations. Creates a three-year statute of limitations for conditional payment recovery actions brought by the government.

The changes made to the  provisions for penalties should come as a relief to carriers, patients, and their lawyers and doctors who were previously under threat of stiff penalties in any case of mis-reporting or under-reporting to CMS.  Changing the language to “may be subject to (penalties)” allows for penalties to be ordered in cases of fraud or misrepresentation but does not require penalties in cases where mistakes are made.