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DTCI: New Medicare reimbursement and reporting law

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By Nicholas C. Pappas and Jeffrey J. Mortier
 

Pappas_Nicholas.jpg Pappas
Mortier_JeffreyBW Mortier

On January 10, 2013, President Barack Obama signed into law the Strengthening Medicare and Repaying Taxpayers Act of 2012 (“SMART Act”). When finally implemented, the SMART Act should streamline settlement negotiations and provide more certainty to settlements involving Medicare beneficiaries.

The SMART Act will significantly modify Medicare’s Secondary Payer requirements to be more efficient, workable and user-friendly. Using a secure website, claimants, insurers and self-insureds should be able to obtain information about payments for which Medicare claims it is entitled to reimbursement and will be entitled to rely on that information when claims are paid (so long as proper notice is given). In addition, entities required to report payments to Medicare beneficiaries will likely be given some reprieve from the harsh penalties for noncompliance with Section 111’s reporting requirements when good-faith efforts are made to report a potential third-party claim.

Key elements of the SMART Act include:

(1) Medicare must provide claimants, insurers and self-insureds with access to a secure website that contains information relating to payments made by Medicare that may be subject to reimbursement from any potential settlement, judgment, award or other payment.

(2) Claimants, insurers and self-insureds may give notice to Medicare of a potential settlement, judgment, award or other payment within 120 days of the potential settlement, judgment, award or other payment. Medicare then has 65 days to provide its reimbursement amount. If proper notice is provided, the claimants, insureds and self-insureds that have obtained consent of the claimant then may rely on the last statement of reimbursement amount downloaded from the Medicare website so long as the statement was downloaded within three business days before the date of the settlement, judgment, award or other payment. The amount downloaded is then considered the “final conditional amount” subject to recovery by Medicare.

(3) Claimants who believe there is a discrepancy in the final conditional payment amount may provide documentation to Medicare explaining the discrepancy. Medicare then must respond to the discrepancy within 11 days. However, this discrepancy process does not take the place of a formal appeals process and the Act requires Medicare to promulgate regulations establishing an appeals process.

(4) Medicare must establish thresholds for both conditional payments and Section 111 reporting. The thresholds are designed to prevent Medicare from expending more money in collection efforts than it stands to receive on a given claim. The thresholds are to be established on Nov. 15 of each year beginning in 2014.

(5) Section 111’s per diem failure to report penalty is now discretionary, as Medicare “may” subject a claim to “a civil penalty of up to $1,000 for each day of noncompliance.” In addition, Medicare must give notice of proposed regulations in which sanctions will not be imposed for non-reporting, including when good-faith efforts to report have been undertaken.

(6) Within 18 months of the enactment of the Act, Medicare must modify Section 111’s reporting requirements so that Social Security account numbers and health identification claim numbers are not required.

(7) A three-year statute of limitations for Medicare Secondary Payer actions is established.

In order to take full advantage of the law, it will be important to notify Medicare in advance of settlement conferences and mediations, to obtain consents from claimants to access information on the amounts claimed by Medicare, and to download the final conditional payment amount within three days of any settlement conference or mediation.•

Mr. Pappas and Mr. Mortier serve as National Medicare Reporting Coordinating Counsel at Frost Brown Todd LLC in Indianapolis. Both are members of DTCI. The opinions expressed in this article are those of the authors.

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  1. wow is this a bunch of bs! i know the facts!

  2. MCBA .... time for a new release about your entire membership (or is it just the alter ego) being "saddened and disappointed" in the failure to lynch a police officer protecting himself in the line of duty. But this time against Eric Holder and the Federal Bureau of Investigation: "WASHINGTON — Justice Department lawyers will recommend that no civil rights charges be brought against the police officer who fatally shot an unarmed teenager in Ferguson, Mo., after an F.B.I. investigation found no evidence to support charges, law enforcement officials said Wednesday." http://www.nytimes.com/2015/01/22/us/justice-department-ferguson-civil-rights-darren-wilson.html?ref=us&_r=0

  3. Dr wail asfour lives 3 hours from the hospital,where if he gets an emergency at least he needs three hours,while even if he is on call he should be in a location where it gives him max 10 minutes to be beside the patient,they get paid double on their on call days ,where look how they handle it,so if the death of the patient occurs on weekend and these doctors still repeat same pattern such issue should be raised,they should be closer to the patient.on other hand if all the death occured on the absence of the Dr and the nurses handle it,the nurses should get trained how to function appearntly they not that good,if the Dr lives 3 hours far from the hospital on his call days he should sleep in the hospital

  4. It's a capital offense...one for you Latin scholars..

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