Medicare Advantage Plans Using MMSEA Data, Post-Settlement: It will get worse before it gets better.
Jeff Signor
May 21, 2014

At Franco Signor we are seeing a steady increase in post-settlement requests being sent from Medicare Advantage Plans (MAPs) to claimants looking for confirmation of coverage.  The reason this is happening is simple: CMS requires defendants to report settlements with Medicare beneficiaries.  Included in the long list of data in such Reports is information about the defendant and/or Third-Party Administrator (TPA) adjusting such claims.  Once a MMSEA Report is submitted, the data is shared with MAPs.  Of course, MAPs not want to pay if another “responsible” entity exists, so the letter campaign begins.

We recently assisted a TPA and plaintiff’s counsel in several such situations.  Our recommended remedy was to request that the plaintiff’s counsel send a letter to the inquiring MAP informing it of the settlement, and making it clear to the MAP that the TPA or defendant in the personal injury lawsuit is no longer “responsible” to pay for claimant’s treatment (related or otherwise). 

In a handful of these matters, the claimant was never covered by a MAP until well after the underlying claim settled.  This is leading to what could amount to a significant administrative response as plaintiffs, plaintiffs’ attorneys, defendants and TPAs are left to respond to MAP letters well after a case settles and the matter is closed.  We believe this is only the beginning of the problem and that it will get worse before it gets better.

What could Medicare do to cease such craziness?  Well, for starters, CMS could stop sharing the MMSEA data with MAPS.  The only way MAPS are receiving data about TPAs and defendants is directly related to the post-settlement data being submitted. An additional fix to the anticipated administrative quagmire is for CMS to promulgate a rule surrounding an alleged responsibility to pay for post-settlement care and treatment. 

We do not like to be prognosticators of doom and gloom; however, knowing what we know about the data being reported to Medicare and Medicare’s stated goal of always being a secondary payer, it will definitely get worse before it gets better. 

Call us today.  We can help navigate you through the MSP maze!