Recent Increase in Denial of Medicare Coverage

With quarter three of MMSEA Section 111 reporting for workers’ compensation and no-fault (as well as liability claims with ORM) underway, it appears that the transparency of claims to Medicare has resulted in the denial of coverage to an increasing number of Medicare beneficiaries. Denial of coverage can be very frustrating to a Medicare beneficiary, particularly if the denial is improper. However, the Medicare beneficiary is not without recourse as Medicare has an appeals process that the beneficiary can pursue if they feel that Medicare improperly denied coverage.

Insurance carriers, employers or third-party administrators may be contacted by Medicare beneficiaries who have been denied coverage. When these situations arise it is important to obtain as much information as possible regarding the denial of benefits, such as whether the beneficiary is being denied benefits that are related to a workers’ compensation, liability, or no-fault injury or if the denial is specific to unrelated conditions. It is also important to consider whether there is ORM related to the claim, whether a settlement agreement has been reached and finalized, as well as how the claim was reported to CMS (Section 111 or self-reported).

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CMS Region VI Issues “Handout” to Address Industry Concerns and Liability MSAs

On May 25, 2011, Sally Stalcup, the MSP Regional Coordinator for Region VI of CMS, issued a “handout” in response to recurring questions her office has received, particularly surrounding whether an MSA is required. The handout is Ms. Stalcup’s attempt to provide clarification on several issues including the use of MSAs in liability settlements. For … Read moreCMS Region VI Issues “Handout” to Address Industry Concerns and Liability MSAs

Medicare Conditional Payment Recovery Takes a Back Seat to Settlement Apportionment in State Court

Haro v. Sebelius- Medicare Conditional Payment CollectionThere appears to be increased activity on Medicare conditional payment demands surrounding wrongful death actions as demonstrated in recent case law. This is probably due to the fact that when Medicare seeks to recover payments from a decedent’s estate, recovery rights become blurry and can involve interpretations of both state and federal law. For example, in some cases a state’s wrongful death laws will impact whether Medicare will be able to recover. The consensus among courts appears to be that if medicals are resolved as part of the wrongful death action, then Medicare has a right to recover conditional payments. If medicals are not claimed as part of the wrongful death action, but rather are just an action on the part of the decedent’s heirs, Medicare does not have a right to recover conditional payments.

In Wasson v. Sebelius, 2011 U.S. Dist. LEXIS 77771, July 18, 2011, U.S. District Court, Eastern District of Missouri, Northern Division, the court encountered complicated issues surrounding recovery of conditional payments in wrongful death actions, but also had the task of determining whether the action belonged in State or Federal court. The Plaintiff, Martin T. Wasson (“Wasson”), who brought the wrongful death action individually and as the personal representative of the estate of Margaret Suzanne Wasson (the decedent) was served with a letter from the MSPRC alleging that Medicare was owed $8,327.01 in conditional payments. Wasson initiated an action against the federal government and maintained that any claim of the estate was separate and distinct from the claims of a survivor and that Medicare was entitled only to the estate’s allocated share of the proceeds of the settlement.

The St. Louis U.S. Attorney’s Office on behalf of the Department of Health and Human Services (“Defendant”) received the Complaint and removed the matter to Federal court. Subsequently, Wasson filed a Motion to Remand the matter back to the State court in Marion County, Missouri, where they originally filed the lawsuit. In deciding the Motion to Remand, the Court had to determine whether the action was a matter of state or federal law. Wasson alleged that the matter pertained to state law due to the fact that apportionment of the proceeds of a settlement would be dictated by Missouri law. The Defendant argued that Federal court was the proper venue pursuant to 28 U.S.C. § § 1441 and 1442 (a)[1].

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California Passes AJR 12 in Support of SMART Act

It appears that California is quite outspoken about the fact that it is fully onboard with and in support of the Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2011, also known as H.R. 1063. Due to the overwhelming support of SMART among public entities, business groups, insurance companies, and advocates for accident victims and … Read moreCalifornia Passes AJR 12 in Support of SMART Act