11/13/23 Proposed Data Fields for MSA Data in Section 111 TPOC Reporting.
During a presentation today, the Centers for Medicare and Medicaid Services (CMS) announced they are planning to introduce new data fields for Workers' Compensation
Medicare Set-Aside (WCMSA) information when reporting TPOC data via Section 111. CMS emphasized this is for workers' compensation TPOC reporting only, not for liability
or no-fault reporting. Reported information will include total WCMSA amount, period of coverage, a lump-sum or annuity indicator, information concerning annuities, and other
information from the Workers' Compensation Review Center (WCRC) and professional administrators. CMS is proposing layout changes to be complete in early 2024, testing
available in fall of 2024, and implementation in January of 2025. This is an ongoing project, and new information will be reported here as it becomes available.
10/11/23 Final Civil Money Penalty Rules Announced.
The Centers for Medicare and Medicaid Services (CMS) has codified the final version of the rule for civil money penalties related to untimely filing of Section 111 reports.
The rule will become effective on December 11, 2023. CMS will not enforce the rule retroactively; civil money penalties will only be issued for reporting errors found after
the publication of the final rule. CMS will issue a financial penalty against a Responsible Reporting Entity (RRE) if the RRE is found to be non-compliant with the reporting
requirements. Non-compliance is defined as any time CMS identifies a new beneficiary record that was not reported to CMS timely. Timeliness is defined as reporting to CMS
within one year of the date of a settlement, judgment, award or other payment, or the date when an RRE's Ongoing Responsibility for Medical (ORM) payments became effective.
For any record selected via the random audit process, where the Non Group Health Plan (NGHP) RRE submitted the information more than one year after the date of settlement,
judgment, award or other payment (including the effective date of the assumption of ongoing payment responsibility for medical care,) the daily penalty will be:
$250.00 as adjusted annually for each calendar day of non-compliance where the record was reported one year or more but less than two years after the required reporting date.
$500.00 as adjusted annually for each calendar day of non-compliance where the record was reported two years or more but less than three years after the required reporting date.
$1,000.00 as adjusted annually for each calendar day of non-compliance where the record was reported three years or more after the required reporting date.
The maximum total penalty for any one instance of non-compliance by an NGHP RRE for a given record identified by CMS will be no greater than $365,000.00 as adjusted annually.
There will be a safe-harbor where no penalty will be assessed if the RRE can show that it made a good-faith effort to obtain the necessary identifying information to determine
the need to file a Section 111 report.
Hummel Consultation Services is not a Section 111 Reporting Agent on behalf of our clients, but we can assist with any of your Section 111 questions.
THe full text of the Final Rule can be read here.
09/13/23 Changes to the Fixed Percentage Option.
The Centers for Medicare and Medicaid Services (CMS) announced a change to the Fixed Percentage Option, an alternative resolution approach for Medicare Part A/B conditional
payment lien recovery. Previously, this option was only available for liability or workers' compensation settlements with a total settlement amount no greater than $5,000.00.
Effective October 02, 2023, the maximum eligible settlement amount will be increased to $10,000.00. The Fixed Percentage Option provides that eligible lien recovery files can choose
to reimburse Medicare a fixed 25% of the gross settlement value rather than the final lien determination calculated by Medicare. Additional qualifications must be met before
the Fixed Percentage Option can be utilized. The Option applies only to liability and workers' compensation liens that are being recovered by the Benefits Coordination and
Recovery Center (BCRC); hence, the Option is not available for no-fault liens, or liens being recovered by the Commercial Repayment Center (CRC). It has not been addressed
if this Option is available for Medicare Part C or Part D recovery. For additional information concerning lien resolution options, and the Fixed Percentage Option, our
firm would be happy to assist.
02/20/23 Section 111 Civil Money Penalty Extended.
The Centers for Medicare and Medicaid Services (CMS) announced that the publication date for the final version of the Section 111 Civil Money Penalty provision has been
extended to February 18, 2024. The published version of this announcement will be released on February 22, 2023. When enacted, Section 111 required penalties for
certain reporting errors; however, CMS has never clarified the nature and extent of those penalties. Followers of our news feed will recall previous articles wherein
CMS announced potential final versions of the proposed penalties, but those final versions have never been officially published. With this latest announcement, CMS
is declaring that those penalty provisions remain in limbo.
The unpublished announcement can be read here.
01/20/23 New CMS Memorandum Released.
The Centers for Medicare and Medicaid Services (CMS) released a new policy memorandum regarding Medicare Secondary Payer (MSP) compliance on January 20, 2023. The new memorandum
explains and clarifies Medicare Secondary Payer obligations in settlements related to alleged exposure resulting from the use of the herbicide brand "Roundup."
Specifically, CMS details the procedures by which "global" MSP recovery is effected.
Hummel Consultation Services can provide assistance to those attorneys and parties looking for information regarding Medicare recovery in the Roundup cases, and can answer your
questions regarding global recovery.
The complete memorandum can be read here.
12/14/22 2023 Medicare Secondary Payer Compliance Threshold Announced.
The Centers for Medicare and Medicaid Services (CMS) released the threshold amounts for compliance with the Medicare Secondary Payer Act for 2023. As of January 01, 2023, the
threshold for trauma-based liability settlements, judgments, awards and other payments, and no-fault and workers' compensation settlements, judgments, awards and other payments,
without ongoing responsibility for medicals, will remain unchanged from the 2022 value of $750.00. Settlements, judgments, awards or other payments of $750.00 or under have no
conditional payment lien recovery, and do not need to be reported to Medicare via Section 111. The threshold does not apply to liability settlements for alleged ingestion,
implantation, or exposure cases.
Medicare's announcement can be read here.
10/13/22 CMS Withdraws MSP and Future Medicals Notice of Proposed Rule Making.
As per our previous article published on January 10, 2022, the Centers for Medicare and Medicaid Services (CMS) has withdrawn the Medicare Secondary Payer and future medicals
notice of proposed rule making. The rule was intended to clarify existing Medicare Secondary Payer obligations associated with future medical items and services related to
liability, no-fault and workers' compensation insurance. This is only the latest proposal to be withdrawn by CMS, as all proposals since 2018 have been withdrawn.
Withdrawal of the notice of proposed rule making in now way mitigates or lessens the obligations of the parties in a liability, no-fault or workers' compensation case to fully
comply with all provisions of the Medicare Secondary Payer Act (MSP). This includes the obligation to maintain Medicate in a secondary payer position relative to the
The notice of withdrawal can be read here.
08/03/22 Coupon Code for Free Access to myLaw CLE Webinar.
On October 07, 2022 Christine will be speaking live as part of a myLaw CLE webinar titled "2022 Medicare Secondary Payer Update." myLaw CLE has provided a coupon code
to allow free access to this webinar. When registering for this presentation enter the access code HummelConsultation
. If you have any problems using this code please
feel free to let us know! The webinar can be accessed here.
01/10/22 CMS Formally Disallows "Evidence-Based" Set-Asides.
The New WCMSA Reference Guide published on January 10, 2022, includes a new section: 4.3: The Use Of Non-CMS Approved Products to Address Future Medical Costs.
The new section specifically states that CMS does not consider "evidence-based" Set-Asides to protect the Medicare program. "Evidence-Based" Set-Asides first appeared
several years ago by other Medicare Compliance vendors as an alternative to the traditional Set-Aside model, supposedly offering lower Set-Aside determinations by
analyses not necessarily supported by the direct medical record of the claim. A key provision that these other vendors insist upon is that a Set-Aside calculated using
these methods cannot be submitted to CMS for review and approval, and the vendor will
absorb the risk of potential Medicare enforcement.
In their Guide, CMS indicates, "CMS treats the use of non-CMS approved products as a potential attempt to shift financial burden by improperly giving reasonable
recognition to both medical expenses and income replacement... As a matter of policy and practice, CMS will deny payment for medical services related to the WC injuries
or illness requiring attestation of the appropriate
exhaustion equal to the total settlement less procurement costs before CMS will resume primary payment obligations for
the settled injuries or illnesses. This will result in the claimant needing to demonstrate complete exhaustion of the net settlement amount, rather than a CMS approved
WCMSA amount." The Guide specifically identifies "evidence-based" or "non-submit" as non-CMS approved products.
Hummel Consultation Services has never used or endorsed any non-CMS approved product in our Set-Aside analyses or proposals to CMS. Any Medicare Compliance vendor
promulgating these products should be regarded with great scrutiny, especially in light of this new guidance from CMS. As a reminder, Hummel Consultation Services will
review WCMSA analyses from other vendors, and advise our clients if those analyses attempt to circumvent Medicare requirements.
01/10/22 Proposed Rule Changes to be Published in February.
The Centers for Medicare and Medicaid Services (CMS) has indicated that the long-awaited proposed rule clarifying existing Medicare Secondary Payer obligations
associated with future medical items and services related to liability, no-fault and workers' compensation insurance will be published in February, 2022. CMS has promulgated
multiple dates concerning the proposed rule over the past several years but has yet to actually do so. It is unknown at this time if CMS will indeed proceed with the proposed
rule in February as announced. Hummel Consultation Services will continue to watch for this rule and will advise here on our website if the rule is actually published.
The announcement can be read here.
12/15/21 Medicare Secondary Payer Compliance Thresholds for 2022.
As of January 01, 2022, the threshold for trauma-based liability settlements, judgments, awards and other payments, and no-fault and workers' compensation settlements,
judgments, awards and other payments, without ongoing responsibility for
medicals, will remain unchanged from the 2021 value of $750.00. Settlements, judgments, awards or other payments of $750.00 or under have no conditional payment lien recovery, and do not need to be reported
to Medicare via Section 111. The threshold does not apply to liability settlements for alleged ingestion, implantation, or exposure cases.
The threshold announcement can be read here.
12/11/21 PAID Act Implemented.
Changes to the Section 111 Query Response File for Medicare beneficiary Part C and Part D enrollment information as promulgated by the PAID Act have now been implemented.
Section 111 Medicare queries now return information concerning the beneficiary's Medicare Part C and Part D enrollment for the previous three years. Information listed
includes the name of the provider, effective and termination dates, and mailing address for that provider. The information does not include instructions on conditional
payment lien recovery. Recovery of Medicare Part C and Part D conditional payments remains independent from the Benefits Coordination and Recovery Center (BCRC) and the
Commercial Repayment Center (CRC). For claims with a date of injury greater than three years from the date of the Medicare query, the claimant remains the only source
of information for Medicare Part C and Part D plan participation. As a reminder, any Medicare Part C or Part D plan the claimant participates in has a possible right of
recovery in your settlements. Hummel Consultation Services performs Medicare Part C and Part D conditional payment lien searches, and we would be happy to answer any
questions you have concerning the Section 111 changes from the Paid Act.
09/01/21 New Mailing Address for Hummel Consultation Services.
Hummel Consultation Services has relocated from New Hampshire to Indiana! We are very excited to call Indiana our new home, and we look forward to continuing to provide
our customers the best service in the Medicare compliance industry. Our new mailing address for all purposes is:
Hummel Consultation Services
Post Office Box 148
Ferdinand, Indiana 47532-0148
If you would like to send our firm a package via the Postal Service or private carrier, then please contact us for a direct address.
As always, we are available for your questions at any time you would like to call! (603) 758-1410.
06/23/21 PAID Act Timeline.
The Centers for Medicare and Medicaid Services recently held a video conference announcing the timeline for implementation of the changes to the Section 111 reporting
portal to allow for inquiries as to beneficiary Medicare Part C and Part D participation. The new Section 111 user guide will be available on June 11, 2021. The open
testing period will run from September 13, 2021 through December 10, 2021. New HEW software for Section 111 users will be available for download on September 13, 2021.
Changes to the 111 site will appear on October 04, 2021. And the new fields will be fully operational for use on December 11, 2021. As a reminder, Hummel Consultation
Services can answer all of your Section 111 and Medicare Part C/D questions, and our firm does perform conditional payment lien searches for any Medicare Part C or
Part D plan!
12/11/20 New Law Requiring Part C/D Plan Reporting to RRE's.
On December 11, 2020, HR 8900 became law. Title III Offsets; Section 301 requires the Centers for Medicare and Medicaid Services (CMS) to begin providing certain
Medicare Part C and Part D plan information of Medicare beneficiaries to Responsible Reporting Entities (RRE's) beginning December, 2021. Information provided will include
plan names and administrator addresses. CMS must provide the RRE with this information within a three year period; at this time, it is unclear when the three year period
begins to run. The objective of the law is to make it easier for parties in a settlement situation to identify Medicare Part C and Part D providers and to obtain conditional
payment data from those providers. Under the Medicare Secondary Payer Act, Medicare Part C and Part D providers have the same recovery rights as does traditional Medicare
Parts A and B. Beneficiaries, however, also share the same rights as regards conditional payment lien recovery from Medicare Part C and Part D providers.
Hummel Consultation Services already provides complete Medicare Part C and Part D conditional payment lien research services to our clients. We anticipate this new law may
assist with identifying Medicare Part C and Part D plan participation by claimants, as at this time the only source for that information is the claimant directly.
The text of the law can be read here.
12/11/20 Medicare Set-Aside Proposed Rule.
The Centers for Medicare and Medicaid Services (CMS) is scheduled to publish a proposed rule regarding Medicare Set-Asides in March 2021. You may recall from our previous
News posts that publication of the proposed rule has already been delayed several times. The proposed rule would clarify existing Medicare Secondary Payer (MSP) obligations
associated with future medical items and services related to liability (including self-insurance,) no-fault, and workers' compensation settlements, judgments, awards or other
payments. Specifically, the rule would clarify that an individual or Medicare beneficiary must satisfy Medicare's interest with respect to future medical items and services
related to such settlements, judgments, awards, or other payments. The proposed rule would also remove obsolete regulations.
The announcement of the proposed rule can be found here.
11/25/20 Medicare Announces 2021 Threshold.
As of January 01, 2021, the threshold for trauma-based liability settlements, judgments, awards and other payments, and no-fault and workers' compensation settlements,
judgments, awards and other payments, without ongoing responsibility for
medicals, will remain unchanged from the 2020 value of $750.00. Settlements, judgments, awards or other payments of $750.00 or under have no conditional payment lien recovery, and do not need to be reported
to Medicare via Section 111. The threshold does not apply to liability settlements for alleged ingestion, implantation, or exposure cases.
Medicare's announcement can be read here.
10/13/20 Discount on Tuition for Upcoming CLE with Christine.
Christine will be a featured speaker at the Live Video Webinar titled Medical Malpractice 2021, sponsored by the National Business Institute (NBI.) Use promo code
FSP50N at registration to receive $50.00 off the standard tuition for each person registered for the course. The Webinar is
scheduled for Wednesday, December 16, 2020,
from 10:00am through 5:00pm Eastern. If you would like additional information please contact HCS, or follow this link
07/01/20 Proposed Rule for Medicare Set-Asides.
The Centers for Medicare and Medicaid Services has updated the publication date for the Advanced Notice of Proposed Rulemaking regarding Medicare Set-Asides. The new
publication date is August, 2020. An earlier Advanced Notice of Proposed Rulemaking was released in December of 2018; however, that notice was delayed. Medicare's abstract
concerning the Proposed Rule specifically notes that the rule will clarify that an individual or Medicare beneficiary must satisfy Medicare's interest with respect to
future medical items and services related to such settlement, judgments, awards or other payments. The Proposed Rule would also remove obsolete regulations. It is unknown
at this time if the Proposed Rule will finally be released, but HCS will continue to monitor and will report here immediately if the release occurs.
Medicare's announcement can be read here.
02/28/20 Medicare Advantage Plans Not Time-Barred by Three Year Claims Filing Provision.
One February 13, 2020 the Eleventh Circuit Court of Appeals published its holding in MSPA Claims v. Kingsway Amigo. In this case the court determined that the provision
within the Medicare Secondary Payer Act that limits the time period on which to file a claim for recovery for conditional payments, beginning on the date upon which the item
or service was furnished (42 USC 1395y(b)(2)(B)(vi)), does not apply to litigation suits brought by Medicare Advantage plans. The court determined that the time period to file
suit as outlined in 42 USC 1395y(b)(2)(B)(iii) (which states, "an action cannot be brought by the United States unless the complaint is filed no later than three years after
the date of receipt of the notice, settlement, judgment, award, or other payment,) is the more appropriate statutory provision to determine if a
lawsuit is timely filed by a Medicare Advantage plan.
Given this decision by the court, it is important for all parties to determine prior to settlement if the injured party has ever participated in a Medicare Advantage plan
at any time from the date of injury up to and including the date of settlement. If Medicare Advantage plan participation is confirmed, then the parties should contact the
appropriate plan administrator and determine if the plan is entitled to reimbursement of conditional payments.
Hummel Consultation Services includes conditional payment lien searches for Medicare Advantage plans as part of our available services.
The text of the case can be read here.
02/18/20 Proposed Rule for Section 111 Civil Money Penalty (CMP).
The Centers for Medicare and Medicaid Services has proposed a rule of when to assess a Civil Money Penalty (CMP) against a Responsible Reporting Entity for Section 111
Medicare is proposing that a CMP be assessed against an RRE when the RRE has an error reporting amount above the newly established error reporting
threshold of 20%.
If an RRE has an error rate of 20% in their Section 111 reporting for 4 out of 8 consecutive reporting periods, then a CMP will be assessed.
The maximum penalty will be $1,000.00 per day for each individual where a Section 111 report was not filed, up to $365,000.00 per year. The maximum penalty will be adjusted
annually as per 45 CFR 102.3.
Under the proposed tiered-penalty system:
The first offense will result in a fine of $250.00 per day;
The second offense will result in a fine of $500.00 per day;
The third offense will result in a fine of $750.00 per day; and
The fourth offense will result in a fine of $1,000.00 per day.
No CMP will be assessed against an RRE if the following provisions can be documented:
The RRE has communicated the need for identifying information to the Medicare beneficiary or their attorney;
The RRE has made at least two written requests and one phone call or one electronic mail request for the necessary information;
The RRE certifies that it has not received a response to its requests for the necessary information; and
The RRE has documented all efforts to obtain the necessary data to facilitate a Section 111 report or determine the need for a Section 111 report.
The Statute of Limitations for a CMP is 5 years from the date of when non-compliance was identified by Medicare.
The proposed rule can be read here.
01/22/20 Medicare Adds Limited Acupuncture Coverage.
Effective January 22, 2020 Medicare will cover 12 acupuncture visits over 90 days for the treatment of chronic low back pain. Coverage is limited to the treatment of
chronic low back pain not associated with an identifiable systemic cause, not associated with surgery, and not associated with pregnancy.
More information can be found here.
01/08/20 Another Plaintiff's Attorney Held Accountable for Medicare Lien.
A fourth plaintiff's personal injury firm has reached a settlement with the United States for failing to reimburse Medicare's conditional payments. The U.S. Attorney's Office
for the Eastern District of Pennsylvania issued a press release outlining the terms and conditions of settlement with a Philadelphia-based law firm. As with the June, 2018
press release from the same U.S. Attorney's Office, this most recent settlement included an acknowledgement that the law firm may have violated the False Claim Act by
wrongfully retaining government funds.
The press release can be read here.
11/29/19 Medicare 2020 Review Threshold Announced.
The Centers for Medicare and Medicaid Services (CMS) announced that the compliance thresholds for 2020 will remain unchanged at $750.00. Liability, workers' compensation
and no-fault settlements of $750.00 or lower do not need to be reported to Medicare, and conditional payment amounts for those settlements do not need to be repaid.
The press release can be read here.
11/25/19 Plaintiff's Attorney Held Accountable for Medicare Lien.
On November 4, 2019, the United States Attorney's Office for the District of Maryland issued a press release announcing the payment of $91,406.98 by a plaintiff's
The U.S. Attorney stated, "We intend to hold attorneys accountable for failing to make good on their obligations to repay Medicare for its conditional payments, regardless
of whether they were the ones primarily handling the litigation for the plaintiff."
This settlement, and the two prior settlements in June of 2018 and March of 2019, show how seriously the United States is taking the issue of reimbursing the Medicare
conditional payment lien timely. HCS can assist in procuring the conditional payment lien in a timely manner for all settlements, as well as work with Medicare in
reducing the final lien determination.
The press release can be read here.
11/20/19 Medicare Again Delays Proposed Rule Making.
For the past several months, the Centers for Medicare and Medicaid Services (CMS) has been delaying proposed rule making for Section 111 financial penalties and changes
to Medicare beneficiary future medical obligations. In their latest reports just received, CMS has again delayed the
anticipated publication dates of both notices of
proposed rule making. The civil money penalty for Section 111 reporting is now expected in December of 2019, and the future medical obligation proposed rule is now
expected in February of 2020. It is important to remember that the notices of proposed rule making are only the first stage of the rule making process, and it can be
months to years before any formal rules are adopted and actually implemented.
The Section 111 press release can be read here.
The future medical obligation press release can be read here.
09/01/19 New Contact Information for Hummel Consultation Services!
We are excited to announce that we have moved our office to a new location in Newmarket, New Hampshire! As follows is our new contact information; please make use of these
new addresses and numbers immediately.
New Mailing Address: Post Office Box 420, Newmarket, New Hampshire 03857
New Physical Address: 501 Kent Place, Newmarket, New Hampshire 03857
Our telephone number has remained the same: (603) 758-1410
New Facsimile Number: (978) 338-8116
Please use the Post Office box for payment of invoices, submission of new referral data (if mailing,) and other items that need a secure location for delivery. The Kent
Place address should only be used for delivery services and parcels requiring signatures or hand-delivery.
08/14/19 Medicare Delays Section 111 Proposed Rule Making.
Although our previous news post of 08/07/19 noted that the Proposed Rule Making concerning Section 111 reporting requirements was to continue as planned, Medicare
announced that the publication date for the proposed rules concerning Section 111 financial penalties have been delayed to October of 2019. Hummel Consultation Services
will continue to update here these important rules developments.
The press release can be read here.
08/07/19 Medicare Delays Proposed Rule Making.
Medicare pushed back the anticipated publication date for the Advanced Notice of Proposed Rule Making regarding a Medicare beneficiary's future medical obligation
under the Medicare Secondary Payer Act to October of 2019. Please review our news article on 12/07/18 for details concerning the Proposed Rule Making. It is important
to note that the Proposed Rule Making concerning Section 111 reporting requirements, as reviewed in our 12/13/18 news article, will continue as planned at this time. Hummel
Consultation Services will continue to track these important developments, which you can continue to read about here.
The press release can be read here.
03/22/19 Law Firm Penalized by Medicare.
The United States Attorney's Office for the District of Maryland issued a press release noting that the Maryland law firm Meyers, Rodbell & Rosenbaum has agreed to pay the
United States $250,000.00 to settle claims that the firm failed to reimburse Medicare conditional payments on behalf of the firm's clients. The enforcement action is the
second such action in less than a year and shows the government's determination to ensure that the Medicare Secondary Payer Act is complied with in liability settlements.
The increase in enforcement actions over the past year shows how seriously the government is taking Medicare Secondary Payer enforcement. Hummel Consultation Services
encourages all law firms to review their Medicare Secondary Payer compliance procedures to ensure full compliance with all aspects of the law. We are available to assist
all of our clients and new customers with Medicare Secondary Payer compliance issues.
The press release can be read here.
03/21/19 New England CLE's by Hummel Consultation Services.
Christine will be speaking live at a number of New England CLE's shortly. Dates, locations and web links are as follows. Be sure to check her out to get all of the latest
updates regarding Medicare Secondary Payer compliance, and to earn credits at the same time!
April 9th: Massachusetts.
April 15th: Connecticut.
April 30th: New Hampshire.
May 9th: New Hampshire.
12/13/18 Notice of Proposed Rule Making.
By September, 2019 the Department of Health and Human Services, and the Centers for Medicare and Medicaid Services, will issue a Notice of Proposed Rule Making regarding
civil penalties imposed by the Section 111 reporting requirement. The Notice indicates that the proposed rule will seek to eliminate obsolete regulations and replace
them with new regulations and practices for which civil money penalties would and would not be imposed. Public comment will be solicited before any final rule is formalized.
A copy of the Notice can be read here.
12/07/18 Notice of Proposed Rule Making.
The Office of Management and Budget posted an alert that by September, 2019, the Department of Health and Human Services and the Centers for Medicare and Medicaid Services
will issue a Notice of Proposed Rule Making under the title, "Miscellaneous Medicare Secondary Payer Clarifications and Updates." The proposed Rule is intended to provide
Medicare beneficiaries an opportunity "to select an option for meeting future medical obligations that fits their individual circumstances, while also protecting the
Medicare Trust Fund." It is important to note that the "Notice of Proposed Rule Making" is the first stage in the rule-making process, and even if a Notice of Proposed
Rule Making is issued in September, 2019, it may still be several months or years before a formal rule is actually implemented.
A copy of the Notice can be read here.
11/15/18 Medicare Secondary Payer Compliance Threshold for 2019.
The Centers for Medicare and Medicaid Services (CMS) announced the threshold for Medicare Secondary Payer Act compliance effective for 2019. No changes were made to the
threshold from 2018, and the threshold for compliance with the MSP Act will remain at $750.00 for all claim types: no-fault, liability and workers' compensation. The
threshold only applies to physical trauma-based
claims, and does not apply for alleged ingestion, implantation, and exposure cases.
Because all cases are unique, Hummel Consultation Services recommends contacting us if you ever have any questions if your case meets the threshold, or how meeting the
threshold will impact your case.
A copy of Medicare's threshold announcement can be read here.
06/18/18 Medicare Compliance via the False Claims Act.
On June 18, 2018 the United States District Attorney's Office for the Eastern District of Pennsylvania issued a press release announcing a settlement with the personal
injury law firm of Rosenbaum and Associates. The firm agreed to pay the United States a settlement of $28,000.00 to resolve allegations that the firm failed to reimburse
the United States for certain Medicare payments the government had previously made to medical providers on behalf of the firm's clients who sought medical care. In addition
to the payment, the firm also agreed to: 1. Designate a person at the firm responsible for paying Medicare Secondary Payer debts, 2. Train that person to ensure the firm
pays those debts on a timely basis, and 3. Review any outstanding debts with that person at least every six months tp ensure compliance. The firm acknowledged that any
failure to submit timely repayment of Medicare Secondary Payer debt may result in liability for the wrongful retention of a government overpayment under the False Claims Act.
Additional information concerning the case can be found here.
05/21/18 New Bill to Encourage Medicare Secondary Payer Transparency.
On May 21, 2018 Congressman Gus Bilirakis (R-FL) and Congressman Ron Kind (D-WI) introduced H.R. 5881, to be known as the Provide Accurate Information Directly (PAID) Act.
Intended to encourage Medicare Secondary Payer transparency, the goal of the bill is to allow insurance companies, attorneys, and individuals the ability to determine a
person's Medicare and Medicaid status more quickly. Specifically, the bill would allow person to quickly assess if an injured party is participating in a Medicare Part C plan,
a Medicare Part D plan, or a Medicaid plan. Parties to a potential settlement would thereby be aware of Medicare and Medicaid issues quicker and more easily than is
currently possible, leading to possibly faster lien resolutions.
The bill is currently in committee, and the text of the bill is not available at this time. The press release announcing the bill can be found here.
01/18/18 Highlights from the CRC Contractor Transition Webinar.
The Centers for Medicare and Medicaid Services (CMS) recently held a webinar to introduce the new Commercial Repayment Center (CRC) Contractor, and to identify certain changes
that will be occurring as a result of the transition. The previous contractor, CGI Federal, has been replaced by Performant Recovery, Inc. Performant will assume all
CRC operations effective 02/12/18. During the transition, the CRC will be unavailable on 02/08/18 and 02/09/18, including the customer service call center, and the
facsimile telephone line. Information available on the Medicare Secondary
Payer Recovery Portal (MSPRP) will only reflect data from 02/07/18 during the transition.
Furthermore, all mailed correspondence must be sent to a new address in Oklahoma City. Medicare's Tax Identification Number will not change as a result of the transition.
Performant emphasized that, at this time, all CRC operations will remain the same. It is safe to assume, however, that
Performant will likely introduce new operations or
procedures as time progresses. Hummel Consultation Services will follow-up with any and all changes made to the CRC.
A complete transcript of the webinar can be read here.
01/01/18 2018 MSP Recovery Thresholds.
Medicare recently announced that the recovery thresholds for 2018 will remain unchanged from 2017, and remains at $750.00 for all claim types: no-fault, liability,
and workers' compensation. The threshold only applies to physical trauma-based claims, and does not apply for alleged ingestion, implantation, and exposure cases.
A no-fault, liability, or workers' compensation total payment that is $750.00 or lower, and is a physical trauma-based claim,
has no Medicare Set-Aside requirement, has no Section 111 reporting
requirement, and has no requirement to reimburse the Medicare conditional payment liens. Hummel
Consultation Services recommends contacting us if you are ever concerned if your claim meets the threshold, as all cases are unique.
11/08/17 Medical Provider Education for Accepting MSA Payments.
The Medicare Learning Network, the educational branch of Medicare, recently issued an article specifically for medical providers, physicians, and other suppliers and
practitioners of medical treatment to educate when a payment from a patient's Medicare Set-Aside arrangement must be accepted. The patient is to advise the physician
or medical provider when they will utilize a settlement, judgment, award, or other payment to pay for their medical care. The medical provider is instructed to bill the
patient directly and to be paid by the Medicare Set-Aside if:
1. The treatment or prescription is related to what was claimed in their settlement, or for that treatment the settlement, judgment, award, or other payment had the
effect of releasing, AND
2. The treatment or prescription is covered by Medicare.
A link to the educational article can be found here.
The release of this article continues to emphasize the importance of utilizing a properly determined Medicare Set-Aside or other future medical arrangement in all settlements
for liability, workers' compensation, and no-fault claims. Furthermore, attorneys representing plaintiffs or claimants are encouraged to provide a copy of this article to
their clients as part of the settlement process, so as to help ensure their clients are well-educated regarding funds specifically set-aside for future medical expenses.
10/26/17 Expansion of Liability and No-fault MSA Reviews.
In a recent bulletin, Medicare announced it is continuing to consider expanding the voluntary review process for Medicare Set-Aside arrangements for liability and no-fault
insurance cases. Medicare will work closely with all related interests in how to best implement this potential expansion of voluntary MSA reviews. Although no time-table
has yet been provided, Hummel Consultation Services anticipates that liability and no-fault MSA's may be regularly reviewed by Medicare as early as 2018. At present,
submission of a liability or no-fault MSA for Medicare review usually returns a response by Medicare that sufficient resources are not currently available for review. It is
important to remember that Medicare's refusal to review a submitted MSA does not preclude the necessity of a MSA in a liability or no-fault settlement. We will continue to
monitor the status of Medicare's expansion and provide any updates to this important development as they become available.
10/05/17 New CRC Contractor.
Medicare announced that the new contract for the Commercial Recovery Center (CRC) has been awarded to Performant Financial Corporation. The contract was previously awarded
to CGI Federal two years ago, when the CRC expanded and assumed responsibility for conditional payment recovery activities directly from Non-Group Health Plans (NGHPs.)
It is too soon to determine if Performant will make any changes to current CRC recovery models, but Hummel Consultation Services will continue to monitor the changeover
and update any new developments as they may occur.
09/01/17 New WCMSA Review Contractor.
Medicare announced their new contractor for review of Workers' Compensation Medicare Set-Aside submissions. The new contractor is Capital Bridge, LLC, in Arlington, Virginia.
No date has yet been provided as to when the new contractor will begin WCMSA reviews, but it may be presumed that the transition process is already underway. Hummel
Consultation Services does not anticipate any changes to the WCMSA review process at this time, but we will keep you updated on all changes as they occur.
07/10/17 Changes to MSA review and submission procedures.
An updated WCMSA Portal User Guide was recently issued, indicating certain changes to review processes and procedures. Sections of the User Guide changed include the following:
Section 12.4.3: Amended Review Process. A submitter may request re-review of a previously approved MSA allocation if all of the following apply:
1. The approved MSA was originally submitted for review between one and four years from the date the re-review is submitted;
2. The new MSA must result in a 10% or $10,000.00 change to the MSA funding (either an increase or a decrease); and
3. An amended review may only be sought once. If a prior amended review has been requested, a second amended review may not be pursued.
Section 12.3.5: File Close-outs of Greater Than One-Year. If additional data is
submitted for review on a file where CMS has issued a close-out letter greater than 12 months ago,
the entire MSA proposal must now be re-submitted as a new proposal with a new Case Identification number.
05/10/17 Pending Medicare Changes to Payment for Medical Care.
CMS issued a Medicare Learning Network bulletin to medical providers regarding submission of payments to Medicare Administrative Contractors (MAC's; Medicare's billing
departments.) The bulletin alerts medical providers that beginning October 2, 2017 the MAC's will no longer pay for medical care that should be paid from a liability
or no-fault settlement. The bulletin is a companion to the changes by Medicare to the Common Working File as described in the CMS notice dated February 3, 2017, which
was announced below.
These recent changes by Medicare send a strong message to the liability and no-fault industry that future medical allocations should be strongly considered in all settlements
where ongoing medical care for the related injury is required, and that Medicare intends to treat liability and no-fault settlements similarly to those procedures already
established for workers' compensation.
The bulletin can be found here.
02/03/17 Impact of Change to the Medicare Common Working File.
CMS issued a notice in February announcing a change to be made to the Medicare Common Working File. Beginning in July, 2017 and fully implemented by October, 2017, Medicare
billing contractors will be instructed in the Common Working File when to deny a payment due to a liability MSA or no-fault MSA. The notice to deny payment will be similar to
the notices already posted to the Common Working File for workers' compensation MSA's. This is a clear indication that CMS is moving in a direction to fully enforce the
statutory requirements of the Medicare Secondary Payer Act, including the requirement that Medicare is secondary to a liability or no-fault settlement.
01/03/17 Bids for a New WCMSA Review Contractor.
Medicare is currently soliciting bids for a new WCMSA Review Contractor. Final bids are due January 30, 2017 at 10:00am. The anticipated award date is June 30, 2017.
The contract term will begin July 1, 2017 and run through June 30, 2022. The full solicitation can be found here.
The solicitation suggests that the review process for liability Medicare Set-Asides (LMSA) and no-fault insurance Medicare Set-Asides (NFMSA) is still in the planning phase, such that
review of these MSAs would not begin until at least July 1, 2018. But there is no actual guarantee that CMS will expand the review process to include liability or no-fault cases.
However, the solicitation for bids does make it clear CMS expects to see an increase in MSA submissions throughout the life of the new contract.
12/21/16 Proposed "Re-review" of approved WCMSA amounts.
Medicare recently announced that they will revisit the task of reviewing its process for addressing requests for CMS to "re-review" otherwise approved Workers' Compensation
Medicare Set-Aside Arrangement (WCMSA) amounts. In 2017, the existing re-review process may be updated to address situations where CMS has provided an approved amount, but
settlement has not occurred and the medical care that supported the approved amount has changed substantially. CMS is also planning to update its process to address
situations where certain states rely on Utilization Review Processes to justify proposed WCMSA amounts. The notice from Medicare may be read here.
Hummel Consultation Services will continue to follow these important developments and post any changes to our website.
12/12/16 Medicare Alert Reminding of Changes to Reporting Thresholds in 2017.
Medicare released a reminder alert regarding the upcoming changes in reporting thresholds for 2017. As per our 11/15/16 News update, the mandatory reporting threshold for
liability, no-fault and workers' compensation Total Payment Obligation to Claimants (TPOC) amounts will be $750.00 as of January 1, 2017. Reporting of TPOC amounts below the
threshold will be accepted but are not required. For complete information please read the entire alert here.
11/15/16 2017 Recovery Thresholds Announced.
Medicare recently released an alert addressing 2017 recovery thresholds for certain liability, no-fault insurance and worker's compensation settlements, judgments,
awards or other payments. Beginning January 1, 2017, the threshold for physical trauma-based liability insurance settlements will decrease to $750.00. The $750.00
threshold will remain the same for no-fault insurance and workers' compensation settlements, where the no-fault insurer or workers' compensation entity does not
otherwise have ongoing responsibility for medicals.
Affected entities are not required to report settlement below the threshold, and Medicare will not seek recovery on applicable settlements below the threshold. It is
important to remember that the liability threshold does not apply to settlements for alleged ingestion, implantation or exposure cases.
Additional information regarding the thresholds can be found here.
09/08/16 Upcoming Seminars Featuring Hummel Consultation Services.
Christine will be a featured speaker this fall at a number of seminars and conferences, including:
- The New Jersey State Bar Association Continuing Legal Education, 9:00am to 1:00pm, on November 14, 2016 at the New Jersey Law Center, One Constitution Square, New Brunswick, New Jersey 08901.
- The Meadowlands Seminar 2016, November 16-18, 2016 at the Hilton Meadowlands Hotel in East Rutherford, New Jersey. Link to Website.
- National Business Institute: Advanced Litigation Strategies for Plaintiff's Auto Injuries, December 15-16, 2016 at the Holiday Inn Portland Airport in Portland, Oregon. Link to Website.
06/09/16 Consideration for Expansion of Medicare Set-Aside Arrangements.
The Centers for Medicare and Medicaid Services recently issued a notice of consideration to expand the voluntary review process of Medicare Set-Aside Arrangements (MSAs)
to include the review of proposed liability insurance (including self-insurance) and no-fault insurance MSA amounts. Currently, CMS will only review proposed MSAs for
workers' compensation. CMS is expected to schedule town hall meetings later in 2016 to solicit ideas to implement the potential expansion. Hummel Consultation Services
will closely monitor this important development and continue to provide any updates to the proposed expansion.
05/17/16 CMS Issues Final Rule for MSP Web Portal Expansion.
Changes made by Medicare to 42 CFR 411.39 were published in the Federal Register and address the Final CP Demand process.
Very few changes were made by Medicare and include: a modification of the definitions
section, clarification of what it means to dispute a line item once and only once when a tentative final is issued under this process, maintaining language referencing
future medical items and services, and outlined specific circumstances when CMS may extend its response timeframe beyond those outlined in other sections of the statute.
The final version of the new rule can be read here.
04/15/16 CMS Broadens Scope of Solicitations for a New WCRC.
The Centers for Medicare and Medicaid Services is currently soliciting for a new Workers' Compensation Review Contractor, or WCRC. On 04/15/16 CMS updated their Statement
of Work to include the processing of other Non-Group Health Plan Medicare Set-aside arrangements. Hummel Consultation Services believes that this may be an early hint
that Medicare may soon begin processing Medicare Set-aside submissions for review for liability cases. At this time, generally CMS will not review
an MSA submission for a liability claim, but will instead issue a "no review" letter. It is important to remember that "no review" letters are not acceptance letters of
Medicare Set-aside arrangements by CMS.
CMS anticipates releasing the official solicitation for a WCRC on or about 06/27/16. The anticipated proposal due date is 07/27/16 with an anticipated award date of
11/07/16. Hummel Consultation Services will continue to follow this important development.
01/01/16 New Final CP Process for Obtaining Lien Demands Prior to Settlement.
Today a new option is now available for obtaining lien demand letters for Medicare Part A/B conditional payment lien searches before actually finalizing your settlements.
If you anticipate settling your case within 120 days of initiating the Final CP Process, a process now exists whereby Medicare will issue their final demand letter before
your settlement is finalized. Due to the complexity of the Final CP Process Hummel Consultation Services recommends
contacting us for more specific information, and if this option is applicable to your settlement.
10/05/15 CRC Goes Online.
As per our previous announcement on July 1st, today the Commercial Repayment Center, or CRC, went online. All new workers' compensation and no-fault secondary payer claims
will now be handled by the CRC instead of the BCRC. All CRC claims are still accessible via the Medicare Portal.
Hummel Consultation Services can still process any Medicare Part A/B conditional payment lien search through the CRC as we always have. The only difference is now we need
a Letter of Authority to access CRC claims. Instructions for providing Letters of Authority can be found
on our website under the "Resources" tab, or by following this link.
If you are interested in assigning Hummel Consultation Services as your Medicare Recovery Agent please contact Christine for more information.
07/01/15 Workload Transition from the BCRC to the CRC.
An announcement in the most recent bulletin from Medicare addresses a workload change for the Coordination of Benefits and Recovery program. Effective October, 2015
Medicare will transition a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination and Recovery Center (BCRC) to the Commercial Repayment
Center (CRC). The CRC will assume responsibility for those cases where Medicare is pursuing recovery directly from a liability insurer (including self-insured entities,)
no-fault insurer or workers' compensation entity as the identified debtor. Beneficiaries and their attorneys will continue to work with the BCRC where Medicare is pursuing
recovery from the beneficiary.
A series of webinars and town hall meetings will be scheduled soon to address the transition. Hummel Consultation Services will update this website with any new information
as it arrives. This transition will have no impact on our current or future referrals.
The bulletin may be read here.
07/01/15 ICD Codes as Limitation to Payments with ORM.
Medicare announced in its most recent bulletin an additional limitation to Medicare
claims payments where insurers or workers' compensation entities have reported to CMS
that they have Ongoing Responsibility for Medicals (ORM). Effective January 1, 2016 where an insurer or workers' compensation entity has reported ORM for specific care,
CMS claims processing will use the information provided by the insurer or workers' compensation entity to determine if Medicare should make a payment for those claims.
Specifically, accurate ICD-9 or ICD-10 code reporting is strongly encouraged by Medicare, as these codes will be used as a determination for payment.
The bulletin may be read here.
04/22/15 Appeal Rights for Applicable Plans.
The Centers for Medicare and Medicaid Services issued a formal policy memorandum on April 22, 2015 outlining the appeal rights of Applicable Plans (including
workers' compensation carrier, no-fault insurance, and liability insurance) when the government seeks Medicare Secondary Payer recovery
directly from the Applicable
Plan. Prior to the issuance of this new formal policy Applicable Plans had no appeal rights. The new appeal rights for Applicable Plans will go into effect on
April 28, 2015.
The full text of the formal policy memorandum may be read here.
04/16/15 REVISED! Medicare Part B Outpatient Therapy Caps.
In our April 1, 2015 News update we reported that the lack of action by Congress resulted in no extension of the exceptions for Medicare Part B outpatient therapy caps.
On April 16, 2015 Congress passed the Medicare Access and CHIP Reauthorization Act of 2015. Passage of this new Act extended the therapy cap
exceptions process through December 31, 2017. Hummel Consultation Services will continue to provide updates on this issue as they arise.
04/01/15 Medicare Part B Outpatient Therapy Caps.
According to MLN Connects, the eNews periodical issued by Medicare, Congress took no action to extending the exceptions for Medicare Part B outpatient therapy caps.
From the April 1, 2015 article: "These caps are the annual per beneficiary cap amounts for occupational therapy and for physical therapy and speech-language pathology
services combined, determined for each calendar year. Based on current law, exceptions to the therapy caps, which are allowed for reasonable and necessary therapy
services above the caps, will be considered only for dates of service through March 31, 2015."
03/02/15 Life Expectancy Tables.
Beginning April 1, 2015 the Centers for Medicare and Medicaid Services will begin utilizing the 2010 Life Expectancy Tables as provided by the Centers for Disease Control
and Prevention National Center for Health Statistics for all Medicare Set-Aside proposal reviews. Hummel Consultation Services already made the necessary transitions to
use the new life expectancy tables.
The link for the new Life Expectancy Tables can be found here.
02/27/15 Appeal Rights Codified by Medicare.
The Centers for Medicare and Medicaid Services published rule 80 FR 10611 on 02/27/2015. This final rule implements provisions of the Strengthening Medicare and Repaying
Taxpayers Act of 2012 (SMART Act) which requires Medicare to provide a right of appeal and an appeal process for liability insurance (including self-insurance), no-fault
insurance, and workers' compensation laws or plans when Medicare pursues a Medicare Secondary Payer (MSP) recovery claim directly from the liability insurance (including
self-insurance), no-fault insurance, or workers' compensation law or plan.
Hummel Consultation Services has always provided assistance with Medicare conditional payment liens on all types of claims, and we will continue to provide this service
to our clients.
The link for the final rule may be found here.
02/20/15 New HCS Reference Document.
Hummel Consultation Services has updated their Zero-Dollar Workers' Compensation CMS Proposal checklist to better reflect recent changes in CMS guidelines, and added a
convenient downloadable reference sheet to better assist our clients. The new guidelines can be found on our Referrals page, here.
The reference sheet can be found on our Resources page, here.
10/08/14 Liability Proposed Rule Making Withdrawn.
The advanced notice of proposed rule making for "future medicals" originally published in the Federal Register on June 15, 2012 has been withdrawn by the Centers for Medicare
and Medicaid Services. No reason was provided by CMS for the withdrawal. The proposed rules were intended to clarify application of the Medicare Secondary Payer Act for
third-party liability and no-fault claims. Although the proposed rules have been withdrawn for consideration, compliance with the Medicare Secondary Payer Act has always
been required for third-party liability and no-fault claims. Withdrawal of the proposed rules does not modify nor nullify the requirements of the Medicare Secondary Payer
Act to maintain Medicare's secondary payer status when settlement dollars are provided in consideration of claims for medical damages made by a plaintiff.
The notice of withdrawal can be found here.
04/11/14 CMS Self-administration Assistance Website.
The Centers for Medicare and Medicaid Services has released an assistance website to help beneficiaries with the administration of their own
Workers' Compensation Medicare Set-Aside accounts.
The link for the website is here.
02/18/14 New Liability Settlement Thresholds.
In compliance with the SMART Act, effective February 18, 2014 the new reporting threshold for Third-Party Liability or No-Fault settlements is $1,000.00.
This represents an increase from the previous threshold of $300.00. Any Third Party Liability
or No-Fault settlement, with a physical trauma basis, and a total settlement value under the $1,000.00 threshold does not need to be reported under Section 111, nor will Medicare pursue recovery
of its Conditional Payment. The threshold does not apply to settlements for alleged ingestion, implantation or exposure cases.
The new threshold also does not apply to Workers' Compensation settlements, which must be reported under Section 111 and are still subject to reimbursement
of the Conditional Payment.
A copy of the Medicare notice may be read here.
02/12/14 Proposed Re-Review Process for Work Comp Claims.
The Centers for Medicare and Medicaid Services posted a memorandum proposing an expansion of the Medicare Set-Aside re-review process for Workers' Compensation claims.
CMS is requesting public comments for the proposed expansion. The public
comment period will close on March 31, 2014. Currently, re-review is available for a limited
number of situations, generally omitted documentation or mathematical error. The expansion proposal is considering a broader array of categories and reasons for
re-review, including interpretation disagreement, treatment plan changes, harmful drugs, price disputes, and other issues.
The entire text of the memorandum may be read here.
HCS will continue to monitor this development and post any changes to the CMS re-review process as they arise.
02/11/14 CMS Restructuring and BCRC Creation.
The Centers for Medicare & Medicaid Services (CMS) announced a new
restructuring plan to be implemented on April 1, 2014. According to CMS:
MSPRC.info will cease to exist as of April 1, 2014. As part of the CMS restructuring of the Coordination of Benefits (COB) and Medicare Secondary Payer (MSP) recovery
activities MSPRC.info will be retired on April 1, 2014. Information that was previously obtained from this site is now located on CMS.gov.
Note: MSPRC.info is no longer being updated and the information contained there is not up to date. For the most updated information visit http://go.cms.gov/cobro
The MSPRC and COB are being merged into one new entity named the Benefit Coordination and Recovery Center (BCRC). The new web address for information is http://go.cms.gov/cobro
Phone number and address for the recovery contractor will remain unchanged.
These changes will not impact any current or new referrals for our clients.
01/16/14 New HCS Fee Schedule.
Hummel Consultation Services announces a new fee schedule effective January 16, 2014 for all new referrals received on or after this date. We are pleased to announce
the addition of several new services, including settlement advisory and MSA necessity letters. Some prices have been increased on some services, while prices have decreased
on others. HCS has kept its pricing relatively fixed since 2006, but unfortunately increasing economic pressures have required us to make some minor increases on some
of our more popular services. We are still more than happy to discuss alternative pricing arrangements on individual referrals, and discounts are available to
high-volume clients. Please contact Joseph Hummel at email@example.com
any pricing questions you may have.
HCS is committed to providing the best service and the most competitive pricing in the Medicare Compliance industry. For details on our current fee schedule, please click on
page, or download the current fee schedule here
12/27/13 Proposed Rule Change for Lien Appeals.
The Centers for Medicare and Medicaid Services issued a proposed rule on December 27, 2013 allowing an insurance provider formal appeal rights when Medicare is seeking
recovery of a Conditional Payment directly from the insurance provider. Currently an insurance provider has no formal administrative appeal rights or judicial review;
any such disputes are addressed by the CMS Recovery Contractor. If approved, the proposed rule would significantly increase the rights of insurance providers to appeal
Conditional Payment recovery efforts by Medicare that the insurance provider believes may be inappropriate.
The text of the proposed rule change may be read here.
09/04/13 Haro v. Sebelius.
On September 4, 2013 the Ninth Circuit Court of Appeals issued its published opinion of the Haro v. Sebelius case. In that opinion the Ninth Circuit overturned the 2009
injunction prohibiting the Centers for Medicare and Medicaid Services from placing Conditional Payment reimbursement efforts into collections while an appeal or waiver
request is pending. Hummel Consultation Services maintains rigorous follow-up procedures for any Conditional Payment search or appeal on behalf of our clients, thereby
lessening the impact of this decision.
The opinion can be read in its entirety here.
01/10/13 Impact of the SMART Act upon Medicare Compliance.
The Strengthening Medicare and Repaying Taxpayers (SMART) Act was recently passed in Congress and was signed by President Obama into law on January 10, 2013. The SMART Act
contains updates on the reimbursement system for conditional payments and slight modifications to Section 111 reporting. The Act makes no provisions for establishing
Medicare Set-Aside allocations.
The full text of the law can be found here.
07/01/12 Hummel Consultation Services Presentations.
Christine Hummel, Esq., President of Hummel Consultation Services, will be performing multiple lectures as part of the National Business Institute's Continuing Legal
Education series on Medicare Compliance. Look for her in-person at the following seminars:
- August 16, 2012, Pittsburgh Marriott City Center, Pittsburgh, Pennsylvania.
- August 24, 2012, World Trade Center, Building 2, Portland, Oregon.
- October 19, 2012, Capital Conference Center, Indianapolis, Indiana.
- October 25, 2012, Milwaukee River Hilton Inn, Milwaukee, Wisconsin.
- November 16, 2012, Cheyenne, Wyoming, location to be announced.
- November 30, 2012, Wilmington, Delaware, location to be announced.
Christine will also be hosting a series of live teleconferences on July 31, 2012 and September 17, 2012 through the National Business Institute.
For information on attending any of the above presentations please visit http://www.nbi-sems.com,
or contact Hummel Consultation
Services. We look forward to seeing you there!
04/06/12 The Medicare Secondary Payer Recovery Portal.
CMS is in the process of implementing a new web-based tool designed to assist in and accelerate the resolution of Liability Insurance, No-Fault Insurance, and
Workers' Compensation Medicare recovery cases. This new tool is called the MSPRP: The Medicare Secondary Payer Recovery Portal. The MSPRP will give users the ability
to access and update certain case specific information online. Activities that currently require written communication or telephone calls will soon be able to be done
through the portal.
The MSPRP will allow: submission of Proof of Representation or Consent to Release documentation, requesting current or updated conditional payment amounts, dispute
unrelated claims listed on the conditional payment letter, and submit case settlement information.
The MSPRP is scheduled to go live in July 2012. Additional details will follow as they are made available.
01/18/12 New Option to Self-Calculate Conditional Payment Amounts.
On February 21, 2012, the Centers for Medicare & Medicaid Services (CMS) will implement an option that allows certain Medicare beneficiaries
to self-calculate Medicare's final conditional payment amount prior to settlement. CMS has provided information including eligibility criteria for this process,
instructions on how to self-calculate the final conditional payment amount, CMS' review process, tips, and an illustrated example. This process will undergo continual
improvements based on user feedback. A future teleconference will be made available by CMS for discussion.
Additional information and instructions can be found here.
11/07/11 New Fixed Percentage Option for Medicare's Recovery Claim.
Beginning November 7, 2011 CMS is implementing a new fixed percentage option available to certain beneficiaries to resolve Medicare's
recovery claim. For beneficiaries who receive certain types of liability insurance (including self-insurance) settlements of $5,000.00
or less, by electing the fixed percentage option they may resolve Medicare's recovery claim by paying 25% of the total liability
insurance settlement instead of using the traditional recovery process.
To elect the option, all of the following criteria must be met:
1. The liability insurance (including self-insurance) settlement is for a physical trauma based injury. This means it does not relate
to ingestion, exposure, or medical implant.
2. The total liability settlement, judgment, award, or other payment is $5,000.00 or less.
3. The beneficiary elects the option within the required timeframe and Medicare has not issued a demand letter or other request for
reimbursement related to the incident.
4. The beneficiary has not received and does not expect to receive any other settlements, judgments, awards, or other payments related
to the incident.
When electing the option, a beneficiary must understand that as part of choosing the option they give up their right to appeal the fixed
payment amount or to request a waiver of recovery for the fixed payment amount.
The fixed percentage option request must be submitted before or at the same time Notice of Settlement documentation is submitted. If
the request is made in response to a Conditional Payment Notice (CPN), it must be received by the response due date referenced in the CPN.
The fixed percentage option election document may be found here.
The form must be completely filled out by the beneficiary or their representative, and mailed to:
MSPRC - Fixed Percentage
PO Box 138880
Oklahoma City, OK 73113
A request for the fixed percentage option will be denied if the case does not meet all of the criteria. If the request is denied,
the beneficiary will receive an explanation of denial, to be followed by a regular demand letter under separate cover. If the request
is approved, the beneficiary will receive a bill for repayment of 25% of the total settlement, which must be paid in the timeframe
specified on the bill.
Complete information may be found at http://www.msprc.info
09/30/11 Two New Policy Memorandums Regarding Liability Settlements.
CMS issued two new policy memorandums clarifying and reiterating the need for Medicare Set-Asides in Third Party Liability settlements.
The first memorandum, issued 09/29/11, states that, for liability settlements, if the treating physician certifies that the injured party's treatment for an injury
or illness has been completed as of the date of settlement, and no future treatment is required for the injury or illness, then no
Medicare Set-Aside will be required in that liability settlement.
The second memorandum, issued 09/30/11, states that, for liability settlements, if the date of exposure occurred prior to 12/05/80, then
no Medicare Secondary Payer obligation exists; i.e. no Medicare Set-Aside or Conditional Payment Lien Search is required. If the exposure
occurred for as little as one day past 12/05/80, then compliance is required
of all provisions of the Medicare Secondary Payer Act.
The two liability memorandums can be found here:
09/06/11 New Threshold on Liability Settlements.
Medicare has implemented a $300.00 threshold for certain Liability Insurance cases. If all of Medicare's criteria are met,
the MSPRC will not recover against the beneficiary's settlement, judgment, award or other payment.
As of September 6, 2011, if a beneficiary receives a lump sum settlement of $300.00 or less, and the case meets certain
conditions, Medicare will not recover from that settlement. These conditions include:
1. The settlement is related to an alleged physical trauma-based incident, not an alleged exposure, ingestion, or implantation, and
2. The beneficiary does not have any additional settlements related to the same alleged incident.
The threshold specifically excludes settlements where an insurer is paying a beneficiary's medical bills directly or on an ongoing
basis. The threshold also does not apply if a demand letter was already issued for the case.
More detailed information can be found in the Attorney and Insurer Toolkits at http://www.msprc.info/
05/11/11 CMS Releases New Workers' Compensation Memorandum.
The latest memorandum released by CMS reiterates the provisions of the CMS memorandums of July 11, 2005 and April 25, 2006. In the
new May 11, 2011 memorandum CMS continues to endorse their guidelines for when submission of a Workers' Compensation Medicare Set-Aside
proposal will be reviewed by CMS. Those thresholds continue to be:
1. The claimant is currently a Medicare beneficiary
and the total settlement amount is greater than $25,000.00
2. The claimant has a "reasonable expectation" of Medicare enrollment within 30 months of the settlement date and
anticipated total settlement amount for future medical expenses and disability/lost wages over the life duration of the
settlement agreement is expected to be greater than $250,000.00
CMS will not review WCMSA proposals if the thresholds are not met. It is imperative to remember that the review thresholds are NOT
"safe harbor" thresholds, and that Medicare beneficiaries must still consider Medicare's interests in ALL workers' compensation cases.
The May 11, 2011 memorandum addresses workers' compensation claims only. This memorandum is not applicable to Third Party Liability claims.
The text of the latest memorandum may be read here: http://www.cms.gov/WorkersCompAgencyServices/Downloads/May112011Memorandum.pdf
04/18/11 The Chicago CMS Regional Office Announces Third Party Liability MSA Review Thresholds.
The following statement was issued by the Chicago CMS Regional Office in April, 2011:
"As you know, the CMS does not require liability set-asides; however, this does not change the attorney and his client's obligation
to take into account Medicare's interest. If a liability settlement includes money for future medical services or if you
believe that significant future medical will be needed for which Medicare would normally pay, then all parties should ensure that
money is set-aside to pay for those services.
The Chicago Regional Office will review a proposal submission on a
case-by-case basis based on the availability of resources. Our Review Thresholds are:
1. The settlement amount must be greater than $250,000.00,
2. The injured party is currently a Medicare beneficiary at the time of submission of the proposal, and
3. This Regional Office will not review a $0.00 proposed MSA."
Please note that this is for CMS submissions to the Chicago Regional Office only, and only applies to liability set-asides.
12/15/10 CMS Boston Regional Office Changes Annuity Rule for Liability MSA's.
Hummel Consultation Services recently confirmed with the CMS Boston Regional Office that the Boston Regional Office only is adopting a new
policy regarding the use of annuities to fund liability Medicare Set-Asides.
The Boston Regional Office will only allow the use of an annuity to fund a liability Medicare Set-Aside if the proposal specifically
states that the injured party will resume any and all Medicare-covered medical expenses for their injury if the funds provided by the
annuity for any given year are completely exhausted. Once the annuity is refilled, then the Set-Aside may resume payments for the
This is in complete contrast with the rules for Workers' Compensation Medicare Set-Asides. The Memoranda issued by CMS in 2004
specifically state that Medicare will pay for the medical expenses for the work-related injury on MSA's funded by
the annuity is exhausted.
The Boston Regional Office indicated to Hummel Consultation Services that their Regional Office will not challenge the 2004 Memo,
but they feel the Memo applies only to Workers' Compensation claims and not liability claims, leaving their Office free to utilize
The significance of this update can be profound, as it clearly shows that at least one CMS Regional Office feels the Memoranda
regarding Medicare Set-Asides do not necessarily apply to liability claims, potentially opening the door for completely different
regulations regarding the use of MSA's in liability claims.
Hummel Consultation Services will continue to follow these updates as they become known.
11/15/10 New HCS Mailing Addresses.
Hummel Consultation Services moved to new offices on November 15, 2010 and are now located in downtown Portsmouth, New Hampshire.
The new mailing address is:
Hummel Consultation Services
Post Office Box 180
Portsmouth, New Hampshire 03802-0180
Please use the Post Office Box for all mail. For parcel delivery, please use the following:
Hummel Consultation Services
600 State Street, Suite 4
Portsmouth, New Hampshire 03801
Our telephone information has remained the same:
Phone: (603) 758-1410
Facsimile: (603) 758-1411
(The x1420 fax line has been removed.) All electronic mail addresses remain the same.
If you have any questions please contact our office!
09/03/10 New HCS Publication.
Christine's latest article, "Third Party Settlements and Medicare" has been published in the September 2010 issue of
the Arizona Attorney. In this article Christine discusses the impact of the Medicare Secondary Payer Act upon all manner
of third party liability settlements, and provides useful practice tips for dealing with Medicare Set-Asides.
The article may be read in its entirety here: http://www.azattorneymag-digital.com/azattorneymag/201009/#pg33
06/08/10 CMS Clarifies the May 14 Memorandum.
Due to confusion from the 05/14/10 CMS Memorandum regarding the use of rated ages in Medicare Set-Aside proposals to CMS
for their review, CMS issued a clarifying statement. The rated age certification now required by the May 14 memo must
"Our organization certifies that all rated ages we have obtained and/or have knowledge of regarding this claimant, and
generated at any time on or after the Date of Incident for the alleged accident/illness/injury/incident at issue, have been
included as part of this submission of a proposed amount for a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)
to the Centers for Medicare & Medicaid Services."
This wording must be used in any proposal where rated ages are utilized, and no substitute wordings are permitted. All other
requirements comprising acceptable proof of rated ages remain unchanged.
A copy of the memo can be found here: http://www.cms.gov/WorkersCompAgencyServices/Downloads/ClarifiedMay142010RatedAgeLanguageJune82010.pdf
05/14/10 New CMS Policy Memorandum.
CMS issued a policy memorandum to clarify their previous memos dated April 3, 2009 and July 1, 2009 regarding prescription
drugs, and the memo dated August 25, 2008 regarding rated ages.
According to the new memo, for a part D prescription drug to be covered by Medicare, and thus included in a Workers' Compensation
Medicare Set-Aside, the drug should be prescribed for an outpatient use that is approved under the Federal Food, Drug, and
Cosmetic Act [21 U.S.C.A. 301 et seq.], or
supported by one or more citations
included or approved for inclusion in any of the
compendia described in subsection (g)(1)(B)(I) or 42 U.S.C. 1395r-8.
Therefore, prescription medications should only be included in the MSA for their FDA approved uses only.
For Work Comp settlements effectuated prior to 06/01/10, and if the settlement included non-covered part D drugs in the WCMSA,
funds for the drugs will be considered an appropriate expenditure of the WCMSA. For Work Comp claims not settled prior to
06/01/10, and if the settlement includes non-covered part D drugs in the WCMSA, those cases may be re-priced and the funds not
used for non-covered part D drugs. For any Work Comp settlement resolved after 06/01/10, and if the settlement does not include
non-covered part D drugs in the WCMSA, those funds may not be used for non-covered part D drugs.
The memo also addressed the use of rated ages in WCMSA proposals. A statement indicating that all rated ages obtained have
been included has been rescinded. The following statement must now be used:
"Our organization certifies that all rated ages obtained on the claimant, at any time during that individual claimant's lifetime,
have been included as part of this submission to the Centers for Medicare & Medicaid Services."
No variations or substitute wording shall be accepted. Acceptable proof of rated ages must still be included with the WCMSA
A copy of the memo may be read here: http://www.cms.hhs.gov/WorkersCompAgencyServices/Downloads/WCMSARXGuidance6109.pdf
03/23/10 Physical Therapy Exceptions.
President Barack Obama signed into law the Patient Protection and Affordable Care Act. A provision in this Act extended the
physical therapy exceptions process until December 31, 2010. This over-rules our previous News post of 01/06/10.
03/23/10 The WCMSA Portal.
Latest update from the Centers for Medicare and Medicaid Services regarding development of the WCMSA Portal:
"The CMS is moving forward with the development of the Workers' Compensation Medicare Set-Aside Portal (WCMSAP). As you know,
the WCMSAP will allow for electronic submission of WCMSA proposals for future medical and future prescription drug costs on a
more expedited basis. With the introduction of the WCMSAP web portal, scehduled for the first quarter of 2011, WCMSA submitters
will receive a real-time acknowledgement of their proposal submissions. Rest assured that comprehensive educational material
will be provided on this website for all interested parties before the implementation of the WCMSAP. Keep checking back for
updates that will be coming from CMS about the WCMSA Web Portal."
01/06/10 Physical Therapy Caps.
Congress chose not to extend the exceptions to the pysical therapy caps for 2010. Therefore, Medicare will only pay $1,860.00
for physical therapy services with no exceptions. Prior to 2010, a list of exceptions existed for certain diagnosis codes. A
diagnosis code appearing on the list of exceptions would allow Medicare to pay any amount for physical therapy so long as the
therapy was considered "medically necessary." With the failure to extend the exception list, now Medicare will pay no more than
$1,860.00 for physical therapy services, regardless of the severity of the injury. Pending legislation in Congress could
potentially extend the cap exceptions, however no action has yet occurred. This is the first time since 2006 that Congress
has failed to extend the cap exceptions.
Hummel Consultation Services will continue to post developments as they occur.
10/26/09 Upcoming HCS Events.
Christine Hummel will be a featured speaker at the following pending events:
Pennsylvania Bar Assocation: The Carlisle Country Club in Carlisle, PA, November 12, 2009.
Kentucky Workers' Compensation Education Association Conference: The Sheraton Cincinnati Airport, KY, December 3-4, 2009.
New Jersey Institute for Continuing Legal Education: The New Jersey Law Center, New Brunswick, NJ, February 12, 2010.
Christine will also have an article published in the "Arizona Attorney," out in late 2009 or early 2010.
06/01/09 Prescription Drug Set-Aside Guidance for Submitters.
Questions and concerns raised from the treatment of prescription medications in WCMSA proposals to CMS as previously addressed in the
April 3, 2009 Memorandum have been answered by CMS in a new statement released June 1, 2009. The text of the new statement can be
Hummel Consultation Services has always completely complied with the issues addressed in this new
statement. Any questions in regards
to prescription medication treatment in MSA proposals may be directed to any of our staff at your convenience.
05/26/09 Regional Office Changes.
The Centers for Medicare and Medicaid Services announced that Medicare Set-Aside proposals for liability cases will be reviewed
by all ten of their current Regional Offices. However, Workers' compensation proposals will now only be reviewed by six of
their current Regional Offices. Effective immediately, the new assignments, as per jurisdiction of the claim, are:
Boston = CT, ME, MA, NH, RI, VT
New York = NJ, NY, PR, VI
Philadelphia = DE, MD, PA, VA, WV, DC
Atlanta = AL, FL, GA, KY, MS, NC, SC, TN
Chicago = IL, IN, MI, MN, OH, WI
Dallas = AR, LA, NM, OK, TX
Kansas City = IA, KS, MO, NE
Denver = CO, MT, ND, SD, UT, WY
San Francisco = AZ, CA, HI, NV, GU, MP, AS, FM, MH, PW
Seattle = AK, ID, OR, WA
Workers' Compensation Proposals:
Boston = CT, ME, MA, NH, NY, PR, RI, VT, VI
Philadelphia = DE, DC, FL, MD, NJ, PA, TN, VA, WV
Chicago = GA, KY, IL, IN, MI, MN, OH, WI
Dallas = AL, AR, LA, MS, NM, NC, OK, SC, TX
San Francisco = AS, AZ, CA, CO, GU, HI, MT, NV, ND, MP, SD, UT, WY
Seattle = AK, ID, IA, KS, MO, NE, OR, WA
Hummel Consultation Services will make all changes necessary to our current or pending Medicare Set-Aside proposals to reflect
the new Regional Office changes. Our customers do not need to take any action in regards to these changes.
04/03/09 New CMS Memorandum Released.
A new Centers for Medicare and Medicaid Services Memorandum was released on April 3, 2009 specifically addressing CMS procedures
regarding the methodology of pricing future prescription drug treatment expenses in Workers' Compensation Medicare Set-Aside
As of June 1, 2009, prescription drug amounts are to be calculated using average wholesale price (AWP). No other pricing,
discounting, or calculation methods will be allowed to determine the adequacy of the prescription drug amounts. This effectively
eliminates the use of "dount-holes," out-of-pocket expenses, and any other discounts commonly used by other MSA vendors.
Hummel Consultation Services has never utilized these illicit means to lower prescription drug costs in its MSA proposals, nor
have we ever endorsed the use of such. All of our MSA calculations effective immediately shall utilize the average wholesale price
method endorsed by CMS.
Any staff member of Hummel Consultation Services may be contacted to discuss questions you may have regarding this very important
Memorandum issued by CMS.
The full text of the new memorandum can be found here
03/24/09 Liability Settlements and Medicare Set-Asides.
The Centers for Medicare and Medicaid Services recently held a conference call regarding the impending mandatory insurer reporting
requirements. In an important development, CMS indicated that liability settlements must also protect Medicare's interests by ensuring
the Medicare program does not pay for future medical expenses caused or necessitated by the injury or illness that is the subject of the
liability settlement. CMS further stated that no formal review process is presently in place for liability Medicare Set-Asides but that
the absence of this formal review process does not indicate a "safe harbor" that would excuse a liability settlement from protecting
Medicare's interests. CMS further announced that the six regional CMS offices will make a decision on a per-office basis if that
particular office will review liability Medicare Set-Asides. The decision is to be based on the workload on the specific regional office.
To date, the only regional office to provide information on liability reviews is the Dallas office, which has verbally indicated that it
plans to begin reviewing liability Medicare Set-Asides as early as June 2009.
We will continue to monitor these important changes regarding liability settlements and will immediately post
all new information on this website as it is received.
Hummel Consultation Services is a leading provider of liability Medicare Set-Asides, and we would be more than happy to accept your
liability referrals or answer any questions you may have. Please feel free to contact any of our staff for more information.
09/15/08 Implementation Timeline for Medicare Extension Act of 2007, Section 111, released.
As a follow-up to our News article of 12/29/07, below, the Centers for Medicare and Medicaid Services has announced a timeline for
implementation of the Mandatory Reporting Statute for Liability and Workers' Compensation carriers. This implementation is a result of
passage of the Medicare, Medicaid, and SCHIP Extension Act of 2007, 42 U.S.C. 1395y(b)(7)&(b)(8), specifically in regards to Section 111,
the Medicare Secondary Payer Mandatory Reporting Provisions.
The timetable for liability insurance (including self-insurance,) no-fault insurance, and workers' compensation is as follows:
January 1, 2009 - June 30, 2009 : Recommended systems development period.
May 1, 2009 - June 30, 2009 : Electronic registration via the COBSW for all liability/no-fault/workers' compensation RREs.
July 1, 2009 - September 30, 2009 : Testing period for all liability/no-fault/workers' compensation RREs.
October 1, 2009 - December 31, 2009 : All liability/no-fault/workers' compensation RREs must submit their first Section 111 production files based upon a predetermined schedule with the COBC.
January 1, 2010 : All liability/no-fault/workers' compensation RREs must be submitting Section 111 production files by this date.
RRE = Responsible Reporting Entity, COBSW = Coordination of Benefits Secure Website
The entire memo addressing this timetable can be found here
08/28/08 New CMS Policy Memorandum Released 08/25/08
The Centers for Medicare and Medicaid Services released a new policy Memorandum on August 25, 2008. This Memorandum focuses on two
1. CMS issued specific guidelines regarding the handling of implantable devices, such as spinal cord stimulators,
in set-aside allocations. CMS submissions must now include detailed pricing information regarding the device. Failure to provide this
information will result in CMS utilizing its own cost-finding methodology. As a rule, Hummel Consultation Services has always included
detailed pricing information for all items included in our CMS proposals.
2. CMS rescinded the rules outlined in Question 10 of
the 07/11/05 Memorandum regarding the ability of beneficiaries to request terminations of MSA funding. Effective immediately, beneficiaries
will no longer be allowed to request a termination in funding to their set-aside accounts for any reason.
A complete text of the new Memorandum can be found here
08/27/08 New CMS Regional Office Assignments
Effective 09/01/08, CMS rearranged the number and assignments of their Regional Offices, removing four offices and retaining six. The four
offices removed are Atlanta, Denver, Kansas City, and New York. The states serviced by those offices are reassigned to the remaining locations.
The following link provides a list of the new assignments: link
The new assignments are as follows:
Boston = CT, ME, MA, NH, NY, PR, RI, VT, VI
Philadelphia = DE, DC, FL, MD, NJ, PA, TN, VA, WV
Chicago = GA, KY, IL, IN, MI, MN, OH, WI
Dallas = AL, AR, LA, MS, NM, NC, OK, SC, TX
San Francisco = AS, AZ, CA, CO, GU, HI, MT, NV, ND, MP, SD, UT, WY
Seattle = AK, ID, IA, KS, MO, NE, OR, WA
Hummel Consultation Services will apply the new office assignments for all of its current and pending CMS proposals; no action is necessary
on the part of our customers!
07/15/08 Extension of Therapy Cap Exceptions
Legislation enacted 07/15/08 extends the effective date of the exceptions process to the therapy caps to 12/31/09. For physical therapy
and speech language pathology services combined, the limit on incurred expenses is $1,810.00 for calendar year 2008. For occupational
therapy services, the limit is $1,810.00. Deductible and coinsurance amounts applied to therapy services count toward the amount
accrued before a cap is reached.
This legislation is an extension to that discussed in our news article for 12/29/07, below.
05/21/08 Hummel Consultation Services to Host MSA Seminar
Christine Hummel, in association with Ringler Associates, will be presenting a comprehensive seminar on Medicare Compliance
at the Pontchartrain Convention Center in New Orleans, Louisiana on June 20, 2008 at 9:00am. All aspects of Medicare Compliance
will be covered, including disputed claims, liability issues, and the Medicare lien search process. This seminar is appropriate
for anybody concerned about Medicare compliance issues arising within their settlements, and is especially useful for claims
adjusters, attorneys, and self-insured business owners.
Those involved in Longshore and Harbor Workers' disputes, and Jones Act disputes, may find this seminar to be especially beneficial.
Attendance is free for all; however, space for this important conference is limited, so be sure to reserve your spot as
soon as possible.
For further information or to make a reservation, please contact Keith Christie at Ringler Associates by phone at (504) 454-9520, or by e-mail at
CMS Memorandum Released
The latest CMS Memorandum regarding the official policies of the Medicare Secondary Payer Program as it relates to Workers'
Compensation was released today. This short Memorandum only addressed the correct life expectancy tables to be utilized when
determining Medicare Set-Asides, and identified the correct table as the CDC Table 1, "Life table from the total population."
Effective July 1, 2008, CMS will only accept MSA proposals utilizing this table.
The change will only affect proposals made after the July 1st date. It will have no impact upon rated age determinations.
The text of the latest CMS memo can be found here
A copy of CDC Table 1 can be found here
. Click the link for the 2004 tables.
Legislation: Federal Notification and Penalties
President Bush signed Senate Bill 2499 into law at the end of 2007. Section 111, Paragraph 8 of the bill requires that
by July of 2009, all liability, no-fault, and workers' compensation laws and plans, including self-insureds, must
construct a plan that complies with the following provisions:
1. The insurer must make a determination whether a claimant, including individuals with unresolved claims, is entitled to benefits under
the Medicare program on any basis, and
2. If the claimant is entitled to Medicare, to submit to the Secretary of Health and Human Services the following:
A. The name of the claimant,
B. Any other such information in order to make an appropriate determination concerning coordination of benefits,
including any applicable recovery of benefits (i.e. to assert a lien.)
The information must be submitted to the Secretary within the time specified by the Secretary after the claim is resolved through
settlement, judgment, award, or any other payment issued, regardless of a determination of admission or liability.
An applicable plan that fails to comply with the requirements of Section 111, Paragraph 8 with respect to any claimant shall be subject
to a civil money penalty of $1,000.00 for each day of noncompliance with respect to each claimant.
Despite the passage of this Bill, several issues remain unclear at the present time. First, no indication was provided of when carriers
must specifically give notice to the Secretary of the above provisions. Second, the law is vague regarding what precise information must
be provided. It is hoped that the Centers for Medicare and Medicaid Services will provide additional clarification well before the
provisions of this bill come into effect in July of 2009. Hummel Consultation Services will update this important release as it discovers
The full text of Bill 2499 can be found here
. Search for Bill Number S2499.
12/29/07 New 2008 Physical Therapy Caps
Senate Bill 2499, signed into law at the end of 2007, provides for new physical therapy cap amounts.
In 2008, the annual amount for physical and speech therapy (combined) is $1,810.00.
In 2008, the annual amount for occupational therapy is $1,810.00.
Congress took action late in December 2007 to extend the physical therapy cap exception process to June 30, 2008. Additional action
shall be necessary by Congress to extend the cap exceptions beyond this date. The text of the exception process can be found in
Senate Bill 2499, Section 105, here
. Search for Bill number S2499.
05/25/07 Lumbar Artificial Disc Replacement
The Centers for Medicare and Medicaid Services is considering a proposed change regarding lumbar disc replacement procedures.
Currently, artificial lumbar discs are authorized for persons over the age of 60, with one specific type of disc exempted from
this policy. The proposed change will remove coverage for all
artificial lumbar disc replacement procedures for all
persons over the age of 60, regardless of the type of disc used.
The text of the proposed change can be found here
03/14/07 CPAP Coverage Re-Evaluation
The Centers for Medicare and Medicaid Services is reconsidering the coverage of testing criteria and usage of
Continuous Positive Airway Pressure (CPAP) therapy for obstructive sleep apnea (OSA). No change has been made
to current coverage, but this may change depending upon the outcome of their evaluation.
The text of the reconsideration can be found here
02/05/07 New Depression Coverage Consideration
A proposed decision for VAGUS Nerve Stimulation coverage.
The text of the proposal can be found here