Medicare Serious About Set-Asides (Again)

Those $1,000-a-day penalties sound improbable? At the very least, expect the CMS to be geared up to begin enforcing Medicare set-asides come January.

By MATTHEW BRODSKY, senior editor/Web editor of Risk & Insurance®

Those on the front lines of Medicare set-asides report back that the government is not aggressively enforcing the $1,000 per day penalties that it can impose on violators of the Medicare reporting rules.

Ohio: Bureau issues amendments on provider certification (03/25/13)
Oregon: Division seeks input on common funds claim balance (04/29/13)
California: Division addresses good-faith negotiations (04/15/13)
Washington: Emergency rule focuses on medical provider network (04/01/13)
Rhode Island: Division spells out information on cost-of-living increase (04/18/13)

As Jim Pocius, shareholder at law firm Marshall, Dennehey, Warner, Coleman & Goggin, explained to the audience in a morning session at the Annual National Workers' Compensation and Disability Conference® & Expo, the government is more interested in getting information from claims-payers. Have you settled a claim, and if so, can Medicare collect any money from it?

Still, enforcement is finally around the corner: Jan. 1, 2011. The government is ready for the go-live date, according to Russell Whittle, senior staff counsel at Gould & Lamb LLC.

It appears that many claims payers aren't prepared either, based on what the session speakers have seen. Sure, large payers like insurers Zurich and ACE are well prepared, said Pocius. But with midsize and smaller payers, there's "definitely change and difference in the amount of knowledge that they have (about the set-aside process)," Pocius said.

Whittle still hears from clients who aren't prepared at this late date.

Jake Reason, technical director, Medicare set-asides, at CompPartners Inc., agreed that smaller payers just aren't prepared. They haven't done this type of reporting before and don't have the technical capabilities or resources to handle it.

"I'm concerned for those types of organizations," he told the audience.

One thing all payers can keep in mind, Reason explained, is the point of view of the CMS. They are intent on making sure the agency doesn't pay for anything in a settlement it shouldn't. Claims adjusters, on the other hand, just want to settle and the payer might typically wait until after a claim is settled to figure out the set-aside. Medicare's position must be considered earlier than that.

"If you don't play by their game, you're going to get burned," Reason said.

November 10, 2010

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