Thereb s nothing worse than a late hit. As experts in Plaintiff’s MSA and Lien Solutions, we see these too often. Most likely, you never even see it coming. You roll with the punches, win your case, and win a settlement for your client. Case closed, right? Wrongb &because thatb s when the blow comes. Medicare starts denying payment of settlement-related bills because they know about your clientb s settlement. They know everything, your clientb s settlement amount, how much money was spent in attorneyb s fees, litigation costs and liens, and the ICD-9 or ICD-10 disease codes that were settled as part of the case. The feeling that this is going to come back to bite you is unshakeableb &but just you wait.
You didnb t report your client to Medicare, and your client didnb t report themselves, so how does Medicare know all of this? The only way you client would self-report is if they had become Medicare eligible post-settlement. A Medicare Secondary Claim Development (SCA) Red Letter and questionnaire would have compelled them to self-report.B However, your client was Medicare eligible on or before theB date of settlement. B That only leaves one possible entityb &the defendant. What is their motivation to report your clientb s settlement to Medicare? B A big, bad, scary stick in the form of the Section 111 Medicare Secondary Payer Mandatory Report. The first part of the law is shown below:
The language used in this mandatory Medicare liability settlement reporting requirement is disturbingly vague, leaving a lot of questions. What exactly are the defendants reporting about you and your client? How much information are they turning over, and when? The answers are alarming. B
How Plaintiff’s MSA and Lien Solutions Can Help
Here is what we discovered:
There are 196 data points within a Section 111 report, and three of them are critical to plaintiffs. They are:
(1) The date of settlement.
(2) The total amount of the settlement, otherwise known as the Total Payment Obligation To Claimant or TPOC.
(3) The ICD-9 or 10 codes that describe the injuries or conditions settled as part of your clientb s case.
Thatb s it. Yet, if these three points arenb t alarming enough, just imagine what is reported in the rest of the data pointsb &all 193 of them.
All of this information is reported at the date of settlement, meaning the date the settlement agreement is signed or the date that you have a court order approving the settlement if you need that. The responsible reporting entity (usually the defendant or the self-insured) that does not report a Medicare-eligible beneficiaryb s liability settlement to Medicare is subject to $1,000 per day, per claimant penalty. The exact text is shown below:
What does all of this mean for your client? Once this information is reported, Medicare files it away for future use. The expectation is that Medicare is now, from the date of settlement forward, B secondary payer to the settlement your client has just received for all of the future Medicare-allowable, accident or incident related expenses covering the conditions or injuries that were the subject of the settlement. Those ICD-9 and ICD-10 disease codes? Those are matched up with future medical bills. A match means payment is denied, and your client is left footing the bill until they can prove they have spent their TPOC on Medicare-allowable bills, after which Medicare covers everything for the rest of clientb s life. If your clientb s settlement money has already been spent, or otherwise allocated, it gets worse. In the end, your client may be left with insufficient funds to both take care of denied payments and all of their other needs. And who are they likely to take it out on? Most likely itb s you. An angry phone call, a bar complaint, a malpractice claim? One or all of these could be your fate.
Donb t let this happen to you. Put proper planning in place from the very beginning, and take control of your clientb s Medicare issues with the Plaintiffb s MSA and Lien Solution. What you don’t know about Medicare reporting and skillful use of strategically minimized (and still voluntary) MSAs to avoid major client Medicare issues can affect your time, money and reputation. Let us help you through it. Sign up for our free video training series: How to Avoid Stress, Reduce Risk and Save Money in Cases Involving Liability MSAs, Structured Settlements and Lien Resolutions.
MORE MONEY AND BETTER SETTLEMENTS FOR PLAINTIFFS.B LESS STRESS, RISK AND WORRY FOR TRIAL ATTORNEYS.