On Wednesday, Centers for Medicare and Medicaid (CMS) published a tool on their website that provides information on how well the hospitals care for all their adult patients with certain medical conditions or surgical procedures. For the first time, consumers of medical treatment can objectively research the quality of care obtained at various hospitals. The data can be accessed at www.hospitalcompare.hhs.gov MEDVAL     1-888-SET-ASIDE (1-888-738-2743)     Medicare Set-Aside Allocation/Arrangement Recommendations     Submissions to Centers for Medicare and Medicaid Services     Post-Settlement Administration     Pharmacy Benefit Management

        

Centers for Medicare & Medicaid Services

CMS Reports Lower Medicare Part D Costs Than Expected in 2009 The Centers for Medicare and Medicaid Services (CMS) recently announced in a Press Release that, based on bids submitted by Medicare Part D plans, CMS estimates that the average monthly premium that beneficiaries will pay for standard Part D coverage in 2009 will be $28.  CMS reports that this is approximately 37 percent lower than the original estimate for 2009 of $44.12, which was made at the time the Medicare Prescription Drug, Improvement and Modernization Act of 2003 was enacted.  CMS also reports that the average expected premium for basic coverage in 2009 is about $3 higher than the actual average for 2008.  CMS attributes the $3 increase to general trends in drug costs, the phase out of a CMS demonstration project, and higher plan estimates for catastrophic coverage based on prior experience. In addition to announcing the average premiums for 2009, CMS also announced: (i) the 2009 national average monthly bid; (ii) the base beneficiary premium; (iii) the regional low income subsidy premium amounts for 2009; and (iv) the 2009 Medicare Advantage regional preferred provider organization benchmarks.  That information can be found here.     Medicare Set-Aside Allocation/Arrangement Recommendations     Submissions to Centers for Medicare and Medicaid Services     Post-Settlement Administration     Pharmacy Benefit Management

        

In his August 4th “Cheap, Fast or Good” blog post, Joe Paduda says:

“There are those on both sides of the political debate (and some who fancy themselves in the middle) who use anecdotes, scary stories, hyperbole and highly elastic versions of 'true' stories to support their solutions to our present health care insurance disaster. While both sides are guilty, I'd have to say the free marketers look to be 'guiltier.' Case in point - I'm on the distribution list (at least at the time of this writing) for a few PR firms that have been hired by conservative types to get bloggers to espouse the libertarian, it-ain't-broke-that-bad-so-don't-fix-it perspective on health care reform. And they tend to try to scare the crap out of everyone with horror stories of waiting lists in Canada, patients expiring in the UK on transplant lists, and folks with furrin accents invading American hospitals as they try to get kidneys or MRIs or gall bladder surgery without waiting till three years after they're dead. And these are the reputable folks - there's also a lot of misinformation circulating in the webosphere about bad Canadian health care”.

Maybe, maybe not. Who really knows after everyone gets their PR firms to slant the facts? But today, while attending an OB appointment, I got a first hand story of Finnish healthcare from our midwife who cares for an ailing 72 year old mother. The discussion centered around whether her mother would be eligible for Medicare as a non-US citizen (the answer is that she can “buy” Medicare Part A and Part B if she has lived in the US for at least five years, is at least 65 years old and has permanent resident status) and whether she would be better cared for here in the United States or under the socialized Finnish system.
 
Apparently several years back, while the mother was still in Finland, she was hospitalized for a bladder infection. Prior to being admitted, she told the doctors that she was predisposed to such infections and that was the likely cause of her current ailment. Despite her self-diagnosis, this poor lady spent three months in the hospital before being properly diagnosed! The conclusion? No way was this US certified midwife going to send her mother to lanquish back in Finland.
 
So that’s it, point proved, no further discussion needed on US health policy.
 
And it was a girl!

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Medicare US Healthcare Socialized Medicine Medicare Set-Aside Turbo Tagger

        

Last week, the Centers for Medicare and Medicaid Services (CMS) published proposed guidelines in the Federal Register regarding implementation of the new liability and no-fault reporting requirements set forth in Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007. CMS's recommendations for compliance with the new reporting requirements are published in the Federal Register with an invitation for public comments on the methods for collecting and submitting such information and the means of enhancing the quality of data.
 
When the Extension Act was passed in December 2007, the statute required that, beginning July 1, 2009, insurers would be obligated to determine benefit status of all Claimants and report the claim to the Secretary of Health and Human Services to essentially put Medicare on notice so that its interests remain protected. Agencies that fail to comply with the reporting requirements will be fined $1,000 per day per claimant. At the time of this Act's passage, limited guidelines were issued to help insurers understand and meet CMS's expectations. These proposed guidelines are the first step in designing a process to simplify reporting requirements in conjunction with the Act.
 
In addition to the Federal Register publication, CMS has authored a Supporting Statement to further elaborate on proposed reporting guidelines. The Supporting Statement includes clarification on frequency of submitting information and field requirements (mandatory, optional, and situational). Additionally, it provides definitions for types of insurance plans obligated to comply with the new law.
 
All in all, we believe this is a solid effort on CMS's part to provide better guidance for compliance and expectations pending the implementation of the Extension Act next year. While the comments and concerns of the public and industry leaders may (and hopefully will) influence CMS such that this process becomes as efficient as possible, we expect that some guidelines will change over the months.
 
CMS has created the following website to follow instructions as they are developed: www.cms.hhs.gov/MandatoryInsRep/
and comments to the guidelines can be published at http://www.regulations.gov on or before September 30, 2008.
 
For questions and guidance about how to implement your own reporting protocol in advance of the July 1, 2009 deadline, contact MEDVAL or Ask Jen. 


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Medicare Medicaid SCHIP Extension Act 2007 CMS Reporting Requirements Liability MSA CMS Update Federal Register Medicare Set-Aside Turbo Tagger

        

This week, the Government Accountability Office (GAO) issued a report which revealed some glaring problems with CMS's ability to spot and avoid fraud in light of what has been deemed a pending solvency crisis.

The GAO created two fictitious durable medical equipment (DME) suppliers which spent the last year billing CMS for services and products despite that both "companies" did not provide complete documentation in their applications, owned no inventory, and served no clients. All three indicators should have provided ample evidence to CMS that further inquiry would have been appropriate. Although no CMS funds were misused in this experiment, the GAO stated that CMS has put "millions of dollars" at risk by failing to adequately verify supplier legitimacy. This should be a major concern for Medicare who has improperly paid over $1 billion for DMEPOS supplies between April 2006 and March 2007. CMS, while agreeing with the results of the study, issued a statement reminding concerned citizens and lawmakers that programs are being implemented to reduce what has recently become a major issue of Medicare fraud with initiatives such as the competitive bidding program for DMEPOS.

While CMS has established some programs and Congress has enacted statutes to protect its solvency (such as the Medicare Secondary Payer statute and the Medicare, Medicaid, and SCHIP Extension Act of 2007), this study proves that there continue to be many areas that the CMS administration overlooks. In fact, the GAO used words like "simple" and "easy" to describe the challenge to defraud Medicare for this study.


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Medicare solvency GAO report DMEPOS Fraud Medicare Set-Aside Turbo Tagger

        

Just today, H.I.G. Capital announced it has entered into an agreement to acquire PMSI from AmerisourceBergen Corporation (ABC) during the third quarter of 2008 for $40 million. 

This poses the question: How was H.I.G able to acquire all three business lines of PMSI for just $40M? It was just in Q4-2006 when PMSI acquired MSA provider Health Advocates for $83M and now, less than 2 years later, the entire company was sold for less than half of that amount.  Even more puzzling is the fact that Medical Services Company's pharmacy division (supposedly smaller than PMSI's pharmacy division) was just sold for $248M.  It leaves one to wonder how bad things really are at PMSI.
 

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Medicare Set-Aside Industry Mergers and Acquisitions MSA News Pharmacy Benefit Management Turbo Tagger

        

We've recently been receiving a large influx of questions and concerns about Medicare Set-Aside (MSA) allocations for liability and no-fault settlements in light of the new requirements set forth in the Medicare, Medicaid, and SCHIP Extension Act of 2007.

With a pending July 1, 2009, deadline for new reporting requirements, companies are scrambling to put procedures in place to handle the increase in volume. MEDVAL has answers to help guide you through the process of submitting liability MSAs and implementing a compliance protocol for your business to make the change as smooth as possible.

For general questions about liability MSAs, contact liability@medval.com. Or, for more information about the legal requirements of the Extension Act, send your question to our General Counsel at AskJen@medval.com.



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Liability Medicare Set-Aside MSA Medicare, Medicaid, SCHIP Extension Act of 2007 Turbo Tagger

        

Recently, we were asked to complete a Medicare Set-Aside (MSA) for a patient who had recently doubled her dosage of Oxycontin from 40mg to 80mg 3x/day. The reason? A tree was struck by lightening and destroyed her ATV. Apparently this caused her so much emotional distress, she needed to double her narcotic intake.

Note to treating physicians: Sometimes the best prescription is a visit to the psychologist.

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Medicare Set Aside MSA Oxycontin Prescription Drugs Turbo Tagger

        

Earlier today, President Bush vetoed HR 6331 triggering an immediate 10.6% cut in physician reimbursements for doctors who treat Medicare beneficiaries. In no time, the House of Representatives overrode that veto by a whopping 383-41 majority and, shortly after, the Senate followed with a 70-26 vote. The bill's popularity with the public and the medical community is undisputed, receiving widespread support from the AMA and the AARP. Supporters of the bill say the effect of the proposed cuts will discourage doctors from treating Medicare patients.

President Bush said in a statement "I support the primary objective of this legislation, to forestall reductions in physicians payments. Yet taking choices away from seniors to pay physicians is wrong."

The 10.6% cut was set to take place July 1, 2008, as a result of a formula that calls for cuts when spending exceeds established goals. 


Check in with our blog for ongoing Medicare legislation updates.

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HR 6331 Medicare Set Aside Medicare Legislation Congressional Veto Turbo Tagger

        

Earlier this month, the National Alliance for Medicare Set-Aside Professionals (NAMSAP) issued a position letter addressing some of the glaring problems with the CMS review protocol for Medicare Set-Aside Allocations (MSAs). MEDVAL supports the attempts of NAMSAP to gain an audience with CMS. In our experience, every issue raised in the letter is well documented and in dire need of redress. By virtue of its contractor, the WCRC, CMS has overstepped its legal authority and is violating both the letter and the spirit of the Medicare Secondary Payer Statute.

If CMS will not follow its own rules voluntarily, then perhaps it is time for litigation to force a resolution. Hopefully, CMS will heed this call to action and do the right thing.

You can read the entire letter by clicking on the following link: NAMSAP Position Letter

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NAMSAP MSA Protocol Medicare Set-Aside Allocations CMS Policy MEDVAL Policy Turbo Tagger

        

This week, the Senate passed HR 6331, the Medicare Improvement for Patients and Providers Act of 2008, by a sweeping 69-30 majority and is now on the way to the White House. After a complicated run through Congress, HR 6331 allows for a number of improvements in coverage for Medicare beneficiaries. The most notable changes for Parts A & B include improvement in preventive services, reduction in mental health coinsurance rates (to match physical health rates at 20%), and inclusion of intensive cardiac rehabilitation programs and oxygen equipment. Not only that, but the changes to Part D include reinstatement of coverage of barbiturates and benzodiazepines on January 1, 2012, and a revision of the compendia used to determine appropriate indications for drugs (including anticancer drugs).

Furthermore, the competitive bidding program has been delayed for an additional 18 months.

Although none of these changes will immediately affect Medicare Set-Aside allocations, over time we can expect to see larger Part D allocations as commonly used medications that are currently being prescribed for off-label use become "on-label." Similarly, the old theory that benzodiazepines and barbiturates were too dangerous to quality for Medicare coverage (primarily due to their addictive nature) is no longer the case. Both types of drugs are inexpensive and effective if administered and monitored appropriately.

Stay tuned as we follow this legislation and comment on policy changes as they impact the industry.

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HR 6331 CMS Medicare Set-Aside Competitive Bidding DMEPOS Part D MSA Turbo Tagger

        

After taking a beating in the MSA market with its strategy of offering guaranteed MSAs, Coventry has reportedly thrown in the towel. Sources inside Coventry tell us that the guarantee program is officially dead.

In our estimation this was long overdue. Guaranteed MSAs were a product "innovation" that should have never been. While effective as a marketing gimmick, savvy MSA buyers understand that guaranteed MSAs are synonymous with overfunded MSAs.

As the MSA market fragments, firms that offer superior service, expertise in the substantive areas of law, and that render a thorough and thoughtful expert opinion will be tomorrow's winners. Buyers understand that marketing gimmicks are no substitute for  quality work.

Goodbye Coventry guarantee program and good riddance.


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Medicare Set-Aside Guaranteed MSAs Industry News MSA Expert Turbo Tagger

        

 

The Community Pharmacy Fairness Act, or HR 971, has been adamantly supported by the independent drugstore lobby in an attempt to gain collective bargaining rights which could ultimately increase the cost of prescription drugs for Medicare and commercial payors. According to a study published by the Pharmaceutical Care Management Association (PCMA), if this legislation passes, the cost to such payors could increase as much as almost $30 billion over five years. Even more shocking, the costs to Medicare Part D specifically (and its beneficiaries) is estimated to be more than $6 billion in that same time. In an economy where citizens and lawmakers alike are constantly concerned with efforts to preserve the Medicare trust, this bill could serve as quite a blow to the solvency of the program and, ultimately, to beneficiaries themselves who already struggle to stay afloat despite rising pharmaceutical costs and a worsening economy.
 
PCMA is the national association representing pharmacy benefit managers (PBM) which provide low cost prescription drug plans to more than 210 million Americans, including Medicare Part D beneficiaries. As Mark Merritt, President of PCMA, explained, "Independent pharmacists already have a number of legitimate avenues to negotiate with PBMs. This legislation would instead result in employers reducing health insurance coverage for their employees to compensate for increased prescription drug costs."
 
Stay tuned as we track HR 971 and other pending legislation or, for more information, contact MEDVAL.

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Medicare Set-Aside Allocation MSA Medicare Policy Prescription Drug Costs Pharmacy Benefit Management Turbo Tagger

        

Dear Jen:

We are currently working with a WC claimant who was injured in 2000. He did not return to work, applied for SSDI, and was accepted. We had a MSA prepared last year in anticipation of settlement; however, earlier this year he let me know that he had returned to the workforce full time and his SSDI ended back in March 2008. He would still like to settle his case with a lump sum. Is it okay at this point to proceed with a lump sum settlement and will I need to obtain CMS approval on an MSA for this case?

Thanks,
Greg, claims adjuster

Dear Greg:

First, remember that under the Medicare Secondary Payer Statute (MSP), Medicare's interests need to be protected whether or not Medicare approval of a Medicare Set-Aside (MSA) is required per workload review thresholds set forth for workers' compensation claims. To determine whether Medicare has an interest to be protected, I strongly recommend you confirm the claimant's benefit status before you proceed with a final settlement. Just because a claimant returns to work does not mean he loses his Medicare or SSDI eligibility immediately. Return-to-work programs allow Social Security Disability beneficiaries to return to the work force on a trial basis without experiencing the immediate loss of benefits. In fact, a person can work for several months before their SSDI benefits are terminated. Although it sounds like this particular claimant participated in a return-to-work program and his SSDI benefits have been discontinued, under the Ticket to Work and Work Incentives Improvement Act, he may continue to be Medicare-eligible for several years after SSDI benefits have stopped. Therefore, it's very likely that Medicare has an interest that must be protected in settlement of this claim.

Jen

Questions? Ask Jen.  


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medicare set-aside return to work SSDI CMS review thresholds Ticket to Work Act Turbo Tagger

        

David Ralph joins MEDVAL as National Sales Director with over 15 years of business development experience in the workers' compensation managed care arena.  As National Sales Director, David and his team will be responsible for  continuing MEDVAL's growth through new acquisition sales across all MEDVAL product lines.  David's previous experience includes both direct sales and sales management experience
with various managed care organizations including PMSI, Health Net Plus, and American Claims Evaluation. 

David holds a Bachelor of Arts Degree from Western Kentucky University. 


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Staff Profiles MEDVAL Medicare Set-Aside David Ralph Turbo Tagger

        

Dear Jen -
 
Some injured clients have been very relieved that they could count on the security of structured settlement payments but, since medical expenses can start or stutter in any given year, some clients and myself fear running out of the allocated payment money part way through the year even though the overall estimate of yearly medical expenses doesn't really change.  
 
I understand that there is a delay in Medicare coverage picking back up or kicking back in once a beneficiary may have exhausted the yearly allowed payments under the annuity or structure. 
 
Can you please address those concerns or that event of incurring uneven medical expense situation more than the yearly annuity payment under the structure?

-Brad, WC Attorney

Dear Brad -

Clearly CMS contemplated the possibility of structured annual MSA deposits running out since it addressed the issue in one of its memos and provide beneficiaries with the form to easily notify them of the same with every approval letter. We've been able to tell people that once the money runs out, immediately send a notification that your funds are depleted and have your providers start billing Medicare and things will work themselves out on CMS's end. We have never had an issue with the beneficiary of one of our custodial accounts not receiving treatment once their MSA account ran out of funds (and it happens every year with some accounts). Granted, there may be a delay in payment as the paperwork reaches the system; however, the same fine Medicare accounting system that permits payments when there is a primary payer pre-settlement will likely allow the payments to go through without a second thought.

Fact of the matter is that CMS has actually set itself up for an almost guaranteed account depletion in future years by actively telling us all not to account for inflation. In it's approval letter, it provides a year by year annual deposit amount that is flat and equals the exact total amount approved. Given that medical inflation ranges between 6 and 10 percent from year to year, those annual deposits are almost guaranteed to be insufficient in future years. What is particularly troubling is that the industry actually had no objection to funding life annuities with a cost of living increase prior to that memo being released, as that appropriately protected Medicare's interest in the settlement. After the memo we all shifted to temporary life annuities that pay out only the total amount approved at a significant savings (despite the fact the that same memo also prohibits funding MSAs at present value). So not only did CMS basically guarantee that Medicare would be making payment on an annual basis in the later years of the MSA, it also absolutely guaranteed that Medicare would be paying 100% should the beneficiary live beyond his rated age life expectancy.

So although your concerns are valid, they should be for us the taxpayers rather than the Medicare beneficiaries - public policy always prevails and medical treatment will be denied none, especially in light of CMS creating the problem.

-Jen

Questions? Ask Jen.  


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Ask Jen Structured Settlements Annuities Inflation CMS memo Exhausted MSA Funds Turbo Tagger

        

AIG American General recently sponsored an interesting survey about attitudes toward structured settlements. The survey was conducted by Esearch.com and polled 1,000 individuals. 80% of those polled had no direct connection to a personal injury case with the remainder reporting direct or tangential involvement.

The survey posed two hypothetical scenarios involving a car accident and an on-the-job fatality. After being advised of the scenarios, 35% and 73% of respondents, respectively, chose to have their award paid as a structured settlement.  Interestingly, only 7% of people actually invloved in a personal injury situation made the same decision. What's truly shocking is that 64% of attorneys representing the injured parties did not even inform them that a structured settlement was an option.

AIG American General's message is that many more claimants would accept a structured settlement if it were presented to them. Our message is that, in situations involving Medicare Set-Aside allocations, neglecting to inform a client about how a structured settlement can be used to comply with the Medicare Secondary Payer (MSP) statute and put more of the  settlement proceeds into their pocket is a potential source of legal liability. From an Medicare Set-Aside perspective, structured settlements are the best way to ensure Medicare's interests are protected while maximizing the claimant's recovery. 

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Structured Settlements MSA Medicare Set-Aside AIG American General Claimant Funding Medicare Set-Asides Turbo Tagger

        

Mike Leavitt, Secretary of Health and Human Services, announced this week that a $150 million pilot program is being launched to improve the efficiency and accuracy of medical records by encouraging physicians to begin using electronic databases to track medical records and patient care. This program, specific to Medicare, is targeted at 1,200 small practices in 12 regions of the U.S. The program is expected to begin slowly over the next few months and should be fully up and running in 2009. As an incentive to participate in this program, Medicare payments will be increased for physicians who demonstrate they are implementing and utilizing electronic records systems. Eventually, the systems will be used to track and monitor quality-of-care standards and physicians who use the systems for this particular purpose will be receive additional increases in physician payments. Leavitt explained that the cost of increased payments will be largely offset by the savings brought by using electronic systems and, eventually, improvements in health information technology will redefine the U.S. healthcare system.

The 12 regions participating in the pilot program are Jacksonville, FL; Pittsburgh, PA; Madison, WI; Alabama; Delaware, Washington D.C.; Georgia; Maine; Louisiana; Oklahoma; South Dakota; and Virginia.

This is a great initiative not only for Medicare, but for the future of the healthcare system in this nation. Using electronic health record systems will improve accuracy of records by eliminating transcription errors, reducing delays in service and prescriptions, and generally improving the ability to locate and navigate through complicated files. Although there is some concern over privacy (as always with the shift to electronic sources), it should be noted that Americans use electronic record systems for online banking, confidential communications, and other highly personal transactions. So long as the federal government is willing to consistently upgrade electronic systems and find better ways to protect patient privacy, there should be limited concerns over the new program considering the value they add to the delivery of quality healthcare.

As for the Medicare Set-Aside industry, this new pilot program demonstrates not only a willingness but a solid effort from government policy makers to improve the delivery of healthcare and accuracy of patient information. As these changes are made, it is anticipated that eventually MSA submissions may follow suit with more efficient and user-friendly ways to submit MSAs and improve the turnaround time on approvals, ultimately benefitting not only the claimant/plaintiff, but the attorneys and insurers as well. This new pilot program comes at a good time as the change in reporting requirements under the Medicare, Medicaid, and SCHIP Extension Act of 2007 is expected to have a huge impact on the influx of liability and no-fault claims reporting.


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Medicare, Medicaid, SCHIP Extension Act 2007 Medicare Set-Aside Allocation MSA CMS Policy Turbo Tagger

        

The Medicare Set-Aside (MSA) process is complicated and unfamiliar to most claimants and plaintiffs and we at MEDVAL have noticed an influx of questions about how to best explain the need for and purpose of an MSA to someone who does not work in the legal or insurance field, i.e. your injured worker/person. As inquiries continue to come in, we have compiled a list of FAQs to assist attorneys and adjusters when explaining the MSA process. The following are some of the most common and complicated questions to address:

• My attorney says I need to have a Medicare Set-Aside allocation in order for my settlement to be finalized. Is that true?
• Is every Medicare-eligible person (or persons who will become within 30 months) required to have an MSA prepared prior to settlement?
• Who prepares an MSA? How will they know what to include?
• Can my claim be settled before CMS reviews my MSA?
• What if I use more money for Medicare-covered medical expenses than my MSA provided? Will I lose any medical care?
• If I don’t use all of the money in the MSA account, do I get it back?
• What happens if I don’t have an MSA prepared?



Do you have questions about how best to explain the MSA process to a claimant or plaintiff? If so, send them to Ask Jen. 

Contact us for more information on addressing this complicated issue and common questions.


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CMS MSAs medicare set-aside arrangements Turbo Tagger

        

Last week, a study was released by Avalere Health indicating a 16% average increase in the cost of monthly premiums for prescription medications of Medicare beneficiaries. The study was based on the ten largest prescription drug plans in the country which provide coverage for approximately 75% of all Part D-enrolled beneficiaries. While four of these plans reduced premiums this year, six increased substantially enough to drive the cost of monthly premiums up to $26.39. This is a major concern for beneficiaries, most of whom live on a fixed income and cannot afford even the slightest increase without a matching increase in income.

Medicare beneficiaries can switch to a different Part D plan during the open enrollment period of November 15 through December 31, 2008.

Although rising Part D premiums are out of a claimant/plaintiff's control, MEDVAL's services include ways to stretch Medicare Set-Aside (MSA) dollars that save both the recipient and the carrier thousands of dollars.

For more information about our services, including prescription drug savings, contact us today.


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CMS MSAs medicare set-aside arrangements Turbo Tagger