This session at the 2016 California Workers’ Compensation & Risk Conference highlighted three major Medicare issues impacting workers’ compensation today.
- Dan Wynn, Workers’ Compensation Manager, Goodwill Southern California
- John Kane, Medicare Program Director, Liberty Mutual
- Ciara Koba, Partner, Burns White LLC
The SMART Act amended the Social Security Act requiring that Medicare create an online portal for up to date exchange or final conditional payment information. The Centers for Medicare & Medicaid Services (CMS) enacted a workload shift in order to refine the conditional payment process and move towards more-timely notification. Workload transition involves two entities: the Commercial Repayment Center (CRC) and Benefits Coordination and Recovery Centers (BCRC).
Top Three Issues
1. The Commercial Repayment Center (CRC) is impacting workers’ compensation settlements.
Since February, the CRC has issued over 33,000 Conditional Payment Letters (CPLs) and Conditional Payment Notices (CPNs) since the transition in October. The CRC has acknowledged that many insurers and workers’ compensation entities were still awaiting CPNs, CPLs or demand letters, however, they are not consistent in their responses. CRC is having a tough time. They are trying to build knowledge, staffing and keep up with this new workload. CMS working is currently working with the CRC to improve responsiveness, but confusion still looms.
2. Data entered for Section 111 reporting impacts conditional payment recovery.
Section 111 gives Medicare an open look into your book of claims and the data that you enter is going to be important for workers’ compensation Medicare Set Asides (MSAs). Once you report the injury, Medicare is going to treat that as accepted responsibility and is not going to make payment. Occasionally, however, codes related to conditions that the employer is not paying for can make it on to bills and confuses the process. Due to this, Medicare is strongly encouraging that data entered into the system is accurate because the beneficiary could potentially have their benefits discontinued based on what you are reporting.
3. Submission versus non-submission of MSAs.
For CMS submission, there are both pros and cons. The pros of submitting include certainty upon CMS’s review, long-term protection due to the fact that Medicare is not going anywhere and, ultimately, full compliance and low risk. The cons of submitting include inconsistency, unspecific waiting period, no formal appellate rights to appeal and misapplication of state law. You have to evaluate your appetite for risk related to submission. The costs could potentially wipe out the savings you will receive if the submission was accepted.