medicaid & medicare · medicaid & medicare practice tips eisenberg, gilchrist & cutt....
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Medicaid & MedicarePractice Tips
Eisenberg, Gilchrist & CuttCandace Gleed
Damian Huntsman(801) 366-9100
www.egclegal.com
Medicaid
• Insurance provided by the State of Utah• Financial need / disability / low-income
• Statutory requirement to notify of any Third Party Liability• Medicaid – Initial Notification
• Name• Date of Birth• Medicaid Insured Number• Attorney Information• Date of Injury / Loss • Short description of injury / claim• Responsible party
Medicaid Cont.
• Collection Agreement for signature by attorney, injured party• Letter containing adjuster information• Ledger of claimed Lien / Subrogation• Requests for periodic updates for ongoing care by client• Mediation / Settlement
First Initial Medicare Letter
MedicareImportant Facts
• Medicare Parts A, B, C, D (and gap insurance for international coverage)
• Part A –Covers hospital, home health, long-term care• Part B – Covers everything else, physician charges, PT, DME, etc.
• Administered by CMS – BRBC• Part C – Supp Insurance cover co-pays, deductibles, etc.• Part D – Pharmacy
• Administered by private insurance companies
• All programs require reimbursement and notification• 42 CFR 411.24
3 Types of Cases for Reporting
• Liability• At-fault Liability Claims / Policies• Underinsured Claims / Policies• Uninsured Claims / Policies
• No-Fault Insurance• Personal Injury Protection• Med Pay
• Worker’s Compensation
Plaintiff / Defense
• Section 111 Requires Reporting by Insurance Payers• Current $750 threshold to report• Penalties for non-reported cases $1,000 per day per violation
• Requires ICD-9 and ICD-10 codes on the report• Defense required reporting of PIP / medpay claims• Not available to Plaintiffs or beneficiary unless a release is signed• Can affect payment of claims relating to injury• Beneficial for Plaintiffs to review codes / req from adjuster or defense
Conditional Payments
• BRBC • Liability cases• Plaintiff / Beneficiary• Primarily Liability and Workers Compensation cases
• CRC• No-fault cases• Insurance Payors / Defense
• Contractor with claim will handle all disputes, payments, etc.
• Open only one case with Medicare for each applicable claim.
• If a claim for Liability / UIM run consecutive two cases are required to be open
• Use same language to describe injuries in correspondence, cover sheets, etc. to prevent confusion, duplicate cases opened, or unrelated charges being added to lien ledger
CMS.gov Reporting Guidelines
Medicare – Letter / Notice of Case
MSPRP Features & Benefits
Final Demand