MSP Compliance: The Good, The Bad, and The Ugly AASCIF Salt Lake City, UT July 27, 2016

Panel Rafael Gonzalez, Esq. – Vice President – Optum Deb Norsten – Claims Technical Specialist – SFM Bob Martindale – Assistant Director of Claims – Comp Source Mutual

Purpose Claims handling perspective on MSP compliance: – Mandatory Insurer Reporting requirements. – Medicare Conditional Payments resolution steps. – Medicare Advantage Plans reimbursement rights. – State Medicaid agency liens. – Medicare Set Aside allocations. – Seeking CMS approval of set aside allocations. – Administration of MSA account and funds.

Facts Claimant was born on 1/2/50. Claimant works for School District as janitor. Claimant started to receive early SSR benefits on Jan 2012, at 62 years old. Claimant had accident at work on 2/1/2012. Coming down stairs, fell, hit neck and back on concrete steps and rail. C2-3 NHP, L3-4 HNP, encroachment, and radiculopathy.

Claim Denied Claim denied 2/28/12. Not in course and scope of employment. Claimant begins to treat with orthopedic surgeon on 3/1/2012. After time off, therapy, opiods, MRI/CT, ortho recommends surgery on 6/20/2012. Ortho performs laminectomy/discectomy at L3-4 in 8/15/2012. Ortho bills $38,000, Hosp bills $52,000, Therapy bills $24,000, totaling $114,000.

Legal WCJ denies claim, denies TTD, med care and med bills on 10/20/12. Claimant appeals to WCB on 11/1/2012. Claimant applies for SSD on 11/2/2012. Claimant applies for Medicaid on 11/3/2012.

SSD, Medicare and Medicaid SSD awarded on first application as of DOA 2/1/2012 on 12/5/2012. Claimant eligible for higher SSD benefits instead of lower SSR benefits as of 7/1/2012. Claimant receives difference between SSD and SSR benefits from 7/1/2012 to 1/31/2013 Medicaid approves application on 12/5/2012 Providers send med bills to Medicaid on 12/10/2012. Medicaid pays $3,800 to Ortho, $5,200 to Hosp, $2,400 to Therapists on 1/25/2013.

Claim Ruled Compensable WCB finds claim compensable, awards TTD, med bills, and med care on 3/30/2013. Authorized ortho treats conservatively starting 6/10/2013. Ortho recommends pain management on 12/20/2013. Authorized pain management recommends LSI, multiple opiods on 3/15/14.

Medicare A, B, C, and D Claimant completes 2 years of receiving SSD benefits (7/1/2012 to 7/31/2014) Claimant begins receiving Medicare Parts A and B on 8/1/2014. Claimant purchases prescription coverage through Medicare Part D on 8/1/2014. Parts A, B, D premiums too expensive, Claimant switches to Part C on 10/15/2014. Claimant begins MAP coverage on 1/1/2015.

Authorized Medical Authorized pain management recommends psychiatric care on 1/20/2015. Authorized psychiatrist recommends counseling, multiple meds on 3/10/2015. Authorized pain management recommends neurosurgical evaluation on 6/15/2015. Authorized neurosurgeon recommends lumbar fusion on 8/30/2015. Second opinion neurosurgeon recommends SCS on 10/20/2015.

Unauthorized Medical Unbeknown to Employer/Carrier, Claimant treats work comp injury with unauthorized PCP. PCP bills Medicare Part B for diagnosis codes related to work comp claim thru 12/31/2014. PCP bills Part D PDP for medications related to work comp claim thru 12/31/2014. PCP bills Part C MAP for care and meds related to work comp claim starting 1/1/2015.

Unsuccessful Mediation Parties mediate on 12/10/2015. Unaware Claimant was on Medicaid and Medicare, unable to settle file. Agreed to work on Medicaid, Medicare MIR, CPR, and MSA and mediate again.

Mandatory Insurer Reporting Claimant information queried on 1/20/2016. Medicare data shows Claimant is a current Medicare beneficiary on 2/5/2016. Carrier formally reports case through MIR 1stQ2016. Carrier accepted ORM as of DOA 2/1/2012. Carrier reported ICD-10 for cervical and ICD- 10 for lumbar.

Medicare Conditional Payments Called in case to BCRC on 1/20/2016. Received CPL on 3/25/2016 showing $8,400 in conditional payments. Disputed all CP for hypertension, diabetes, cancer on portal on 3/30/2016. Received updated CPL showing $1,750 in conditional payments on 4/20/2016.

State Medicaid Lien Contacted and asked State Medicaid for lien information on 1/20/2016. Received Medicaid lien totaling $11,400 on 3/20/2016. Negotiated reduced reimbursement to $5,000 on 5/15/2016. Received updated Medicaid lien notice for $5,000 on 6/10/2016.

Medicare Advantage Plan Contacted and asked MAP for lien information on 1/20/2016. Received list of payments made by MAP totaling $3,600 on 3/10/2016. Negotiated reduced reimbursement to $2,000 on 5/1/2016. Received updated MAP lien notice for $2,000 on 6/15/2016.

Medicare Set Aside Requested last 2 years of medical records and prescription on 1/20/2016. Received and reviewed medical and prescription records on 3/15/2016. Created synopsis and Life Care Plan on 3/15/2016. Obtained rated age (LE from 14 yrs to 10 yrs) on 3/20/2016. Priced future medical care and prescriptions per SFS on 3/20/2016). Created 2 proposed MSA: fusion/meds $210,000 and SCS/meds $260,000 on 4/10/2016. Submitted MSA to CMS for approval on 5/10/2016. CMS approved MSA as proposed on 5/25/2016.

Post Settlement Parties mediated again on 6/30/2016. Case settled on 7/5/2016. Terminated ORM as of 7/5/2016 on 7/8/2016. Asked BCRC for Part B final demand of $1,750 on 7/8/2016. Asked Medicaid for final demand of $5,000 on 7/8/2016. Asked MAP for final demand of $2,000 on 7/8/2016.

Thank You! Rafael Gonzalez, Esq. – – Deb Norsten – – Bob Martindale – –