Tag Archives: CMS

Skilled Maintenance Services Can Be Covered by Medicare

Today’s post comes from guest author Jon Gelman from Jon Gelman, LLC – Attorney at Law.

A settlement was recently reached in a pending Federal Court case tht will benefit Medicare beneficiaries who require skilled services. The Centers for Medicare and Medicaid Services (CMS) will no longer require that a patient “improve” inorder to be entled to services. Jimmo v. Sebelius, No. 11-cv-17 (D.Vt.), filed January 18, 2011

“New policy provisions will state that skilled nursing and therapy services necessary to maintain a person’s condition can be covered by Medicare.”

See: “Settlement Reached to End Medicare’s “Improvement Standard”

Read more about Social Security

Aug 11, 2012
The Social Security Administration has added to its list of compassionate allowances a pulmonary condition that has been identified as arising out of exposures to burn pits fumes and dusts in Iraq and Afghanistan.
 
Aug 03, 2012
“If a worker becomes eligible for both workers’ compensation and Social Security disability insurance benefits, one or both of the programs will limit benefits to avoid making excessive payments relative to the worker’s past …
 
Aug 13, 2012
An employer cannot stop paying workers’ compensation benefits merely because the injured worker was awarded Social Security Disability benefits. In fact, the premature termination of temporary disability benefits was …
 
Nov 03, 2012
The Social Security Administration has added to its list of compassionate allowances a pulmonary condition that has been identified as arising out of exposures to burn pits fumes and dusts in Iraq and Afghanistan.

 

 

The SMART Act and Workers’ Compensation

United States Congress

Medicare should not pay medical bills that are the primary responsibility of a third party. When they do, they want to be reimbursed, and all parties understand that concept, but the problem is the lengthy delays and lack of due process. The SMART Act, which was signed into law by President Obama on January 10, 2013, amends and reforms the Medicare Secondary Payer Act to improve the reimbursement process. It is located in Title II of H.R. 1845 and entitled “Strengthening Medicare Secondary Payer Rules.”

Section 201 requires CMS to maintain a secure web portal with access to claims and reimbursement information. Payments for care made by CMS must be loaded onto the portal within 15 days of the payment being made. The portal must also provide supplier or provider names, diagnosis codes, dates or service, and conditional payment amounts. Moreover, the portal must accurately identify that a claim or payment is related to a potential settlement, judgment or award. After several steps, the parties may download a final conditional payment amount from the website. If there is a dispute over the conditional payment amount, CMS must respond/resolve the dispute within 11 days or the proposed resolution by the claimant/applicable plan will be deemed accepted. In terms of appeals, CMS must draft regulations that give applicable insurance plans limited appeal rights to challenge final conditional payment amounts. This process will go into effect around April of 2013.

Section 202 states that by November 15th of each year (beginning in 2014), CMS is required to calculate and publish a threshold for liability claims. If an amount owed is under that threshold amount, CMS is barred from seeking repayment.  Section 205 states the statute of limitations for conditional payment recovery by CMS is three years after the receipt of notice of a settlement, judgment, award, or other payment made.

The SMART Act applies to workers’ compensation cases, so it is important to understand the law and how it will be applied in the future. Read it and follow its implementation closely.