|
As a service to our clients and the industry, we post information that we feel
is of value to carriers, self-insured employers and third-party administrators.
Please bookmark this site for easy access to the latest information regarding
current case law, legal and financial implications of the MSP laws and Medicare and Medicaid Services (CMS) updates.
Current Developments:
CMS’ April 3, 2009 Memo Regarding Use of Average Wholesale Price To Calculate
Prescription Medication Portion of Medicare Set-Aside
April 3, 2009 CMS Memorandum
CMS Clarifies Pricing Methodology for Implantable Devices, Ability to Release
MSA Funds, and Proper Use of Rated Ages
CMS Clarifies Use of Life Expectancy Tables for Medicare Set-Aside Proposals
CMS Revises Theshold Limits for Current Medicare Beneficiaries to $25,000.
Current Medicare Interest Rate 11.00%
Effective April 16, 2009, the interest rate for-overpayments and underpayments
will be 11.00 percent. Medicare Regulation 42 CFR §405.378 provides for the assessment
of interest at the higher of the current value of funds rate (three percent for
calendar year 2009) or the private consumer rate as fixed by the Department of
the Treasury. The Department of the Treasury has notified the Department of Health
and Human Services that the private consumer rate has been changed to 11.00 percent.
Case Law Regarding Medicare Secondary Payer Issues:
United States of America, ex rel, Elizabeth Drescher v. Highmark, Inc., 305 F. Supp. 2d 451(E.D. Pa. 2004) A Pennsylvania district court denied Highmark’s motion to dismiss them from the
False Claims Act (FCA) action in which Highmark, which acted both in a private
capacity as a medical insurer and in a public capacity as a Medicare contractor,
allegedly violated the FCA in both capacities by shifting primary payment responsibility
from itself to the Government. The court found causation was potentially the most
problematic element of the FCA claim against the defendant as a private insurer,
but ruled that the claim could go forward.
The Supreme Court denied review of the case for a class action asking whether
an employer with no financial responsibility for the medical bills of its employees
must reimburse Medicare under the secondary payer program.
United States ex rel. Morton v. A Plus Benefits, 10th Cir., No. 04-4148, unpublished 7/19/05. Insured brought a False Claims Act (FCA) claim against its insurer for denying
coverage of certain treatment which was ultimately provided by the federal government.
Insured alleged that denying coverage shifted liability for the treatment to the
federal government and resulted in a false claim being submitted to the federal
government. Since the carrier had a legitimate reason to deny coverage, the FCA
claim was dismissed. The court, however, left open the door as to whether a FCA
claim can be brought if the carrier's denial to pay the claim is not based upon
legitimate reasons.
Newsletters and reports with the latest legal and financial implications of Medicare
laws and regulations:
January 2008 MSP Solutions Newsletter
Centers for Medicare and Medicaid Services Memorandums:
Miscellaneous Items:
|
