Category Archives: Medicare Conditional Payments

Blog, Medicare Conditional Payments

On August 9, 2019, the Commercial Repayment Center (CRC) held an industry conference call and announced it was under mandate to reduce the current backlog of 338,819 conditional payment leads.  Instead of inundating the industry with hundreds of thousands of Conditional Payment Notices (CPNs), the CRC plans to ask Responsible Reporting Entities (RREs) to update their Section 111 data.  By …
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Blog, Legal/Legislative News, Medicare Advantage Part C

The Wild Wild West of Medicare Advantage Organizations (MAOs) filing litigation nationwide against primary plans (workers’ compensation, liability or no-fault carriers/plans) to establish the right to a Medicare Secondary Payer (MSP) private cause of action for failure to reimburse the MAO for unreimbursed conditional payments continues. As of our last update, both the 3rd Circuit (encompassing New Jersey, Delaware and …
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Blog, Medicare Conditional Payments

As a continuing effort to update our readers on the Commercial Repayment Center (CRC), we are providing an update on the CRC’s recovery activities. Franco Signor has been notified that several large insurance carriers have received preliminary notice of a large number of potential debts that the CRC intends to issue Conditional Payment Notices (CPNs) or Demands on. Recall that …
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Blog, Legal/Legislative News, Medicare Conditional Payments, Medicare Secondary Payer News, Pharma Part D

Several of our clients have been experiencing an increase in conditional payment letters from Medicare Part D prescription drug plans. Historically, Part D plans have been less active in recovery of conditional payments than traditional Medicare or Medicare Advantage Part C plans; however, the tide appears to be changing. Why are Part D Plans recently increasing their recovery efforts? One …
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Blog, Legal/Legislative News, Medicare Advantage Part C, Medicare Jurisdiction, Trial Practice

Enforcement of the Medicare Secondary Payer (MSP) Act has been increasingly in the news lately, with results that are alarming for both primary plans and plaintiff attorneys. Primary plans beware: Earlier this week, in an decision entitled MSPA Claims v. Tenet out of the U.S. District Court for the Southern District of Florida, the Court dismissed Plaintiff MSPA Claims’ action …
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Blog, Legal/Legislative News, Medicare Conditional Payments

A new decision by the U.S. District Court for the Middle District of Pennsylvania, entitled United States v. Angino, 2019 U.S. Dist. LEXIS 30499 (February 26, 2019), which involves the United States filing a lawsuit to recover conditional payments from the plaintiff attorney, Medicare beneficiary, and “primary plan” caught our attention.  The lawsuit reignites the debate on whether the parties …
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Blog, Medicare Conditional Payments, Medicare Jurisdiction

As required by section 202 of The SMART Act, CMS is required to annually review its costs relating to recovering conditional payments as compared to recovery amounts. For the last two years 2017-2018, CMS has maintained the threshold of $750 across all non-group health plan (NGHP) lines of business- workers’ compensation, liability, and no-fault insurance. The threshold means that if …
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Blog, Medicare Secondary Payer News, Medicare Set Aside, Pharma Part D, WCMSA

What is the intended purpose behind a Workers’ Compensation Medicare Set-Aside (WCMSA)? The WCMSA Reference Guide, Section 3.0 states: “A WCMSA allocates a portion of the WC settlement for all future work-injury-related medical expenses that are covered and otherwise reimbursable by Medicare (“Medicare covered”) (emphasis added). Accordingly, Medicare through its issued guidance has provided that medical expenses should not be …
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Blog, Medicare Secondary Payer News, Pharma Part D

Recently, CMS updated its Part D Manual to include specific changes to the Manual’s Medicare Secondary Payer (MSP) provisions.  The updated manual can be found here. Page 40 now provides: “Part D sponsors are responsible for adjudicating enrollees’ claims in accordance with MSP requirements. Under CMS’ adjudication logic for Part D MSP claims, the provider/pharmacy receives at least the Part …
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MAPping Out a Course – An Article by Heather Sanderson

08 Oct 2018 Heather Sanderson No Comments

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Primary plans must consider best practices as courts rule in favor of MAPs recovering double damages. Read Full Article from CLM Magazine 

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