Under the SMART Act, the Centers for Medicare & Medicaid Services (CMS) is required to set minimum Section 111 mandatory reporting thresholds for liability claims, as well as establish a “safe harbor” regarding conditional payment reimbursements. For liability claims, this number was originally set as $300 as of September 6, 2011, then raised to $1000…
We bring in-depth analysis, true creativity, and customized solutions to
resolving your Medicare Secondary Payer issues.
At Teague Campbell, we distinguish ourselves from many of the national MSA vendors by doing the creative, analytical file review and analysis that saves our clients money. We take a responsive and personal approach towards serving our clients, and avoid using a formula-driven, “one size fits all” model. We do more than act like a middle man between Medicare and our clients, and would not simply forward requests from CMS without considering the implications. We keep our clients advised every step of the process, and we are accessible at all times. We strive to provide quick-turnaround on files and keep our clients updated on new MSA developments.
With a focused, customized approach, our Medicare team provides clients with substantial cost savings when settling claims involving potential Medicare Secondary Payer issues. Our clients appreciate the experience and accountability we offer in analyzing the complex Medicare issues in Workers’ Compensation and Liability Settlements that many outside MSA vendors simply cannot match. We work with our clients to develop a strategy for addressing and resolving important Medicare issues such as:
- Is the plaintiff a Medicare beneficiary?
- Is there a Medicare conditional payment lien?
- Is an MSA even appropriate?
- How much should be allocated to fund an MSA?
- Can the settlement even be submitted to CMS for review?
- How do we consider Medicare’s interests in a liability settlement if there is no submission process?
- How do we consider Medicare’s interests in a workers’ compensation settlement if it does not fall within the review thresholds?
Before you make the referral, we will provide an informal consultation to determine what steps need to be taken. If no MSA is recommended, then we can provide an opinion letter for a flat-fee rate to document our analysis. If a formal MSA is appropriate, then we can prepare the MSA and make the submission to the Centers for Medicare & Medicaid Services (CMS) for approval, including zero-dollar allocations. If you only need a future medical cost projection, we can assist in getting this prepared. Knowing your case, from initial claim to ultimate resolution, means measurable results, tailored solutions, and real cost savings.
Please contact us for our latest flat-fee and hourly pricing options.
We offer free consultations, either by phone or email, to identify which of our services, if any, are recommended prior to formally engaging our services. Consider us your “lifeline” during mediation or at any stage of your settlement negotiations.
Below is a sample of work we have performed for our clients. Our intention in providing these heavily redacted, concise summary statements is to illustrate the type of work we regularly perform. They do not represent the firm’s entire record and past successes are not a guarantee of any future result or outcome. All identifying case information, as well as references to the parties or counsel involved, have been removed.
- A national MSA vendor recommended $159,171.00 MSA. We prepared a second opinion and submitted $21,006.76 proposal to CMS, which was approved, saving our client over $138,000.00.
- Workers’ compensation case was settled at mediation contingent upon CMS approval of a maximum amount of MSA. We were able to get CMS approval of a $0.00 MSA, which saved the client approximately $43,000.00 on this settlement.
- A national vendor prepared an MSA with future medication costs estimated at $234,319.68. We restructured the pricing using generics, alternative sizing options, as well as equivalent alternative medications, to develop a strategy to reduce the exposure to $121,080.96, for a potential savings of $113,238.72.
- A national MSA vendor recommended $681,602.52. We reviewed the file and assisted the client in projecting the likely exposure and developing a strategy for CMS submission. CMS ultimately approved the MSA for $509,933.00, saving the client $171,669.52.
- Analyzed all potential lien issues in liability settlement with pro se plaintiff, including Medicare Advantage Plan; verified final lien amount under Medicare Advantage Plan, and prepared Medicare language for release.
- Prepared and submitted $0.00 MSA to CMS, which was approved; researched Medicare conditional payment amount; and negotiated payment of final lien with opposing counsel.
- We were contacted by a North Carolina mediator during the course of a live liability mediation and spoke with the attorneys of record to develop strategy to consider Medicare’s interests. Retained to prepare a liability MSA that was incorporated into the settlement.
- Prepared analysis letter for client discussing available options where CMS issued counter-higher demand in response to zero-allocation request from a national vendor.
- Commercial Repayment Center (CRC) issued Conditional Payment Notice (CPN) to a client identifying $30,008.16 in payments. We prepared a response as Authorized Representative, asserting our client was not an Applicable Plan and did not have primary payer responsibility, and the charges were unrelated to the alleged accident. The CRC agreed and reduced the CPN to $0.00.
- A national MSA vendor recommended $116,481.00 MSA. We prepared a new MSA, which was submitted to CMS and approved for $44,624.90, saving our client $71,857.00.
According to a release issued by the Centers for Medicare and Medicaid Services (CMS) late Thursday, June 9, 2016, CMS is again considering expanding its voluntary Medicare Set-Aside Arrangements (MSA) review process to include liability insurance settlements. Per the official release, “CMS plans to work closely with the stakeholder community to identify how best to…
Daniel Hayes Publishes Book on MSAs: Medicare Issues in Liability and Workers’ Compensation Settlements
Medicare Issues in Liability and Workers’ Compensation Settlements by Daniel W. Hayes, J.D., M.S.C.C., was written to guide practitioners through their analysis of how to best consider Medicare’s interests when resolving claims involving medical exposure. The book is presented from the perspective of an insurance defense attorney with over 18 years in practice, who is…
Medicare isn’t the only entity who can sue you for conditional payments – plaintiffs can too!
Daniel Hayes and Tracey Jones presented at the NAMSAP Regional Meeting held in Orlando on January 29, 2015. Their panel discussion, “Protecting the Client,” covered best practices from both the plaintiff and defense perspectives for tackling Medicare Secondary Payer issues in liability and workers’ compensation claims. For information on Daniel and Tracey’s Medicare Set Aside…
We recently learned that the Centers for Medicare and Medicaid Services (“CMS”) withdrew a set of proposed rules which were meant to establish guidelines for liability Medicare Set-Aside considerations. This may not have been so much a function of CMS deciding not to pursue liability MSA rules, but perhaps more a preemptive move by CMS to…
Introduction When resolving a liability claim involving medical treatment, the parties are required by federal law, pursuant to the Medicare Secondary Payer Act (MSP), 42 U.S.C. 1395y(b)(2), to consider Medicare’s interests with regard to the settlement of the medical portion of the claim. The intent of the MSP is to prevent settling parties from shifting…