It has been 17 years since the devastating September 11, 2001 terrorist attacks on US soil. As we move further away from the event however, it is apparent that the list of health conditions related to the toxic chemical exposures at the devastation sites is growing. In addition to the obvious respiratory and psychological illnesses,
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Lyrica has been the subject of recent discussions within the Medicare Set-Aside professional community. Submitters have been surprised to find CMS including Lyrica in WCMSA determinations in situations where it had previously been excluded. Since the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (Version 2.7, March 19, 2018) purports to explain the process used
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Medicare Secondary Payer compliance is an area of practice that is governed by the MSP Statute and supporting Federal Regulations. In addition to the law, the Centers for Medicare and Medicaid Services (CMS) also publishes the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide. The application of the MSP Statute to a particular set of
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In yet another ruling concerning Medicare Advantage Organizations’ rights to pursue the private cause of action under the Medicare Secondary Payer Act, a U.S. District Court in Illinois held that assignee-organizations may pursue rights of recovery on behalf of assignor-MAOs with valid assignment agreements. MAO-MSP Recovery II, LLC. v. State Farm Mut. Auto. Ins. Co.,
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Having revolutionized how we look at everything from baseball, elections to meteorology, it was only a matter of time before predictive analytics were utilized to better manage workers’ compensation claims. According to a recent Business Insurance article, Rising Medical Solutions spent five years polling “high performing” claims organizations and found that they utilized predictive analytics
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Epic Systems v. Lewis & Janus v. AFSCME So far, 2018 has marked a major year of U.S. Supreme Court decisions that affect the employer-employee relationship. Two recent decisions of the Court both have an impact on how an employer manages its business and engages with its employees. First, in Epic Systems v. Lewis,
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In an effort to substantiate a claim for permanent total disability or wage differential, a claimant may embark on a self-directed job search, which can result in significant damage to Petitioner’s case. Self-directed job logs, ledgers and spreadsheets created by a Petitioner should be heavily scrutinized, and can be critical in pointing to a claimant’s
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CMS will consider a proposed Medicare Set-Aside (MSA) when the Total Settlement Amount (TSA) exceeds the one of two review thresholds. The CMS review thresholds are well-known and, for Medicare beneficiaries, is only $25,000. For claimants who have a reasonable expectation of Medicare enrollment within 30 months of the settlement date, the threshold
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The Medicare Secondary Payer (MSP) Act provides that Medicare will make conditional payments for medical services when a primary plan has not made, or cannot reasonably be expected to make, payments for those services. 42 USC §1395(y)(b)(2)(B)(i). If it turns out that the “primary payer” had a responsibility to make those payments, Medicare
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If you’ve got low back pain, you’re in good company. Low back pain is the most common musculoskeletal condition in the adult population, with prevalence up to 84%.[1] The use of advanced imaging (such as MRI) is dramatically on the rise, despite lack of evidence to support its benefit.[2] The fact pattern may
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