Expanded Recoveries on the Horizon
John Williams
April 12, 2017
In a recent blog, Heather Sanderson highlighted the success of MSP Recovery LLC (Plaintiff) certifying a class of Florida Medicare Advantage Organizations (MAOs) that had claims where a non-group health plan (NGHP) failed to make primary payment.   In the filings, the Plaintiff is indicating that they have access to data from the Defendant, MAO, DMV, ISO, and CMS.   With this data, the Plaintiff contends that they can identify Class-Members, medical expenses incurred, and situations in which the Defendant should have been primary.  If accurate, this would be a very useful database, pulling from numerous sources (including the insurers themselves), to triangulate MSP recovery opportunities for MAOs.  In this case, MSP Recovery LLC would like to bring double damages claims in any scenario in which a payment was made by the Florida MAO and there was a primary plan that should have paid. 
We already know that MAOs are receiving Section 111 data from Medicare to assist with their recovery efforts and that CMS agrees that MAOs should have similar rights to traditional Medicare under the MSP.  Through litigation efforts, MAOs have expanded their recovery rights under the MSP in numerous jurisdictions nationwide.  Despite this courtroom success, the Section 111 data alone is not sufficient to identify the recovery opportunity quickly or accurately in many of the cases.  In general, the feedback from MAOs is that the Section 111 data comes late and/or is not detailed enough to identify the recovery opportunity 100% of the time.  The most unique component of the MSP Recovery LLC case is that they are indicating that they have built a piece of software to connect multiple data sources; Section 111 data, MAO data, CMS data, ISO data, and DMV data to triangulate recovery.  This points to advances in the sophistication of the data management system.   MSP Recovery LLC has apparently turned the data from a defunct MAO into a new service offering and revenue stream for the organization, offering recovery services to entities throughout the US as indicated on their website. See a recent article about MSP Recovery in the Daily Business Review here.
We are simultaneously seeing MAOs making investments into the Medicare Secondary Payer Compliance and NGHP Services space.  United Healthcare acquired Helios in 2016 and Blue Cross Blue Shield of Kansas City acquired MedVal. United Healthcare and Blue Cross Blue Shield of KC represent several of the MAOs offered in the market today.  The combined MSP organizations they acquired touch millions of NGHP claims every year.  As we see the increased use of data analytics to sift through large amounts of data and identify revenue opportunities for companies, it is plausible to hypothesize that these organizations are investing in the mature MSP Compliance space for strategic opportunities.  It will be interesting to see if and/or how United Healthcare and Blue Cross Blue Shield of Kansas City use their acquisitions to strategically enhance their organization’s revenue streams in the future. 
Undeniably, the data primary plans share on their claims is in far more hands than it was just 5 years ago and many entities who have access to that data have conflicting strategic and financial objectives.  We are experiencing an unprecedented expansion of recovery efforts against NGHP entities; 1) Medicaid gaining greater recovery rights later this year, 2) MAOs enhancing their recovery rights across the country, and 3) CMS leaving a bread-crumb trail to a LMSA/NFMSA review process over the next 1-2 years. 
As a NGHP entity, where should the efforts be focused first and how can you prepare for the expanded enforcement?  Join us for a webinar as we discuss the next 3 threats on the horizon. Registration link can be found here.
Medicare Advantage Plans, LMSA/NFMSAs, and Medicaid Recovery Rights: What’s on the Horizon?
Medicare Advantage plans are continuing to litigate nationwide to assert their rights to double damages for unreimbursed conditional payments. Class actions are being certified by MAOs to assert these rights against primary payers. CMS is taking steps announced plans toward establishing a voluntary review process for LMSAs and NFMSAs.  The Murray/Ryan Budget deal will allow Medicaid to pursue 100% of their recoveries on settlements beginning October 1, 2017. More states are taking steps to enforce their Medicaid Secondary Payer laws and are enhancing their visibility into settlements with Medicaid beneficiaries.
Join John Williams, CEO, Roy Franco, CCO, and Heather Sanderson, CLO, on May 10th at 1:30 PM EST to learn more about these three very important issues and learn the steps that primary payers can be take now to be prepared.