When an injured worker is a Medicare beneficiary due to age or disability, a Workers’ Compensation Medicare Set-Aside (WCMSA) account is usually required as part of a settlement. The funds in a WCMSA are set-aside in order to pay for future medical or prescription drug services related to the work related injury, illness, or disease that would normally be covered by Medicare. Once the funds in a WCMSA have been used appropriately, then Medicare will start paying for Medicare-covered services related to the work-related injury, illness, or disease. The WCMSA cannot be used to pay for any medical items or services that Medicare does not normally cover.
Workers’ compensation insurance provides 100% coverage of medical treatment for accepted workers’ compensation medical conditions. Medicare, however, requires an 80/20 sharing of medical costs. Without a Medicare supplemental (also called “Medigap”) insurance policy, the injured worker would be required to pay significant co-pays and deductibles. Supplemental insurance is not required by Medicare, but may be helpful to cover the cost sharing required by Medicare, especially if the beneficiary has other medical conditions that are not related to the work injury, illness or disease. However, the premiums for such supplemental coverage cannot be paid out of the WCMSA funds.
While Medicare does not provide coverage for prescription medications, WCMSA funds can be used to pay for medications related to the work injury, illness or disease. If there is a likelihood that the injured worker will exhaust the funds in their WCMSA, then purchasing a Medicare Part D prescription drug plan may be advisable to prevent the injured worker from having to pay full price for their medications once the WCMSA funds are exhausted. However, the financial benefit of having this coverage should be weighed against the cost of plan (2013 national average was $30.00 per month) since the WCMSA funds cannot be used to pay for the plan itself.
For more detailed information about WCMSAs and supplemental coverage, visit www.Medicare.gov.
AARP reports that Dr. Farid Fata in Michigan has been accused of prescribing unnecessary chemotherapy treatments to his patients, including some who didn’t even have cancer. Dr. Fata’s nurse, Angela Swantek, noticed that medications were being administered improperly and patients were in the chair longer than necessary, which created more money for the doctor. Dr. Fata allegedly bilked Medicare for $91 million. Ms. Swantek was afraid of retaliation because Fata “oversees my license.”
The Occupational Safety and Health Act of 1970 (OSHA) has a Whistleblower Protection Program that protects workers from adverse action by employers (such as firing or laying off, blacklisting, demotion, denial of benefits, intimidation, threats, and/or reduction of pay or hours) for exercising their rights under OSHA. An employee has the right to file an OSHA complaint, participate in an inspection, talk to an inspector, seek access to employer exposure and injury records and raise a safety or health complaint with the employer. If your employer does discriminate or retaliate against you, you have the right to file a retaliation complaint with OSHA.
No specific form is required to file a complaint but you can: (1) send a letter to OSHA (to find the contact information for your nearest OSHA office go to www.osha.gov/html/RAmap.html); (2) call the OSHA area office located nearest to you; (3) download and send a completed Notice of Whistleblower Complaint Form to your OSHA area office (www.whistleblowers.gov/whistleblower_complaint.pdf); or (4) file an online complaint (https://www.osha.gov/whistleblower/WBComplaint.html). However, your discrimination complaint must be filed with OSHA within 30 days of the alleged retaliation.
Today’s post comes from guest author Charlie Domer from The Domer Law Firm.
In many workers’ compensation cases, Medicare pays medical treatment expenses for an injured worker that may otherwise be the responsibility of the workers’ compensation insurance carrier. In the past decade, workers’ compensation practitioners have become well-versed in dealing with Medicare issues and establishing Medicare Set Asides—effectively deals between the federal government (Medicare) and the work comp insurance company to cover future work-related medical care for the injured worker.
However, Medicare does not cover all types of medical treatment expenses. Thus, certain types of medical treatment cannot be considered part of a Medicare Savings Account (MSA), but those expenses could still be the responsibility of the insurance carrier. One of those non-Medicare-covered expenses are TENS units for chronic law back pain. On August 1, 2012, the Centers for Medicare and Medicaid Services (CMS) issued a memorandum regarding Transcutaneous Electrical Nerve Stimulation (TENS) units for chronic low back pain. The new CMS policy indicated that chronic low back pain (CLBP) is “an episode of low back pain that has persisted for three months or longer; and is not a manifestation of a clearly defined and generally recognizable primary disease entity.” CMS indicated that for all workers’ compensation cases settled after June 8, 2012, use of TENS units for chronic low back pain will no longer Continue reading
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.