How to Handle Medicare Liens on Personal Injury Cases
While we were all worrying about falling off the fiscal cliff, Congress and the President did something SMART… literally. The SMART Act was signed by President Obama on January 10, 2013. It makes numerous complicated administrative changes to Medicare that effect personal injury cases where the employee or plaintiff is on Medicare and has had treatment paid by Medicare. While most of this may be over the average person’s head, if you stop reading now, just know that something “good” happened to reduce bureaucracy and to speed up settlements that need the federal government’s approval.
For example, when a senior citizen covered by Medicare is treated after an accident or an injury, it’s generally paid for by Medicare. Those medical expenses must then be reimbursed through insurance or a legal settlement. But, the process by which that was to happen has not been running smoothly. The Strengthening Medicare and Repaying Taxpayers, or SMART, Act aims to remedy that.
Many claims involving Medicare beneficiaries could not settle because the parties could not determine their respective obligations to reimburse the federal government in the Medicare Trust Fund. The result was a lose-lose-lose for the beneficiary, the defendant, and the Medicare Trust Fund – all because under the former law, Medicare had no pathway to provide the amount due the Trust Fund for “conditional payments” – those payments previously made by Medicare for the injury that will be covered by the settlement.
The SMART Act fixes this problem by creating a process for Medicare to advise parties in the process of settling, before settlement, of how much is owed, so that the parties can appropriately allocate and resolve their Medicare obligations during settlement. By requiring Medicare to provide the amount due within 65 days of a request, the settling parties will know how much money has to be set aside for Medicare, and factor that amount into their final settlement.
There were numerous other changes. I have summarized some of them for you below. These amendments will require changes to settlement procedure, lien resolution and reporting, and release language. If you are on Medicare and have a personal injury case, make sure you have a lawyer that knows and understands the SMART ACT.
SUMMARY OF SOME OF THE CHANGES
Access to Information About How Much Medicare Paid
Old Law: Did not require Medicare to give immediate access to the conditional payments that were made on behalf of a claimant.
New Law: Up-to-date Conditional Payment Information Available Online
Claimants and responsible reporting entities (RREs, as defined by 42 U.S.C. § 1395y(b)(8)) will now have access to up-to-date information on the claims for which conditional payments have been made by CMS. Again, conditional payments are those payments previously made by Medicare for the injury that will be covered by the settlement. The SMART Act requires CMS to make claims information—including payment amounts and information regarding claims related to a potential settlement, judgment, or other payment—available to claimants or their authorized representatives and RREs (that have obtained the claimant’s consent) through a secure website. This information must be updated no later than fifteen (15) days after the date that payment is made.
Additionally, claimants or RREs now may provide notice to CMS that a settlement, judgment, award, or other payment is reasonably expected and the date of the expected payment up to 120 days before the reasonably expected date of the payment.
CMS already has a web-based portal for claims information, the Medicare Secondary payer Recovery Portal [https://www.cob.cms.hhs.gov/MSPRP/], which appears to satisfy the requirements of the SMART Act. Final regulations must be promulgated by October 10, 2013, nine (9) months after date of enactment, the effective date of this provision.
Pre-Settlement Lien Demands
Old Law: Medicare could not provide a final lien demand until after settlement. The inability to finalize Medicare’s reimbursement interest prior to settlement complicated settlement and lien resolution.
New Law: Establishing Conditional Payment Exposure Prior to Settlement
The SMART Act provides a mechanism by which a claimant or RRE (responsible reporting entities as defined by 42 U.S.C. § 1395y(b)(8)) determines liability for conditional payments prior to a settlement, judgment, award, or other payment for conditional payments. To do so:
- the claimant or RRE (with the claimant’s consent) must obtain a statement of reimbursement amount from the website during the “protected period”—defined as the time, if any, after the expiration of the federal government’s response period following notice of a settlement, judgment, award, or other payment
- the federal government’s response period is 65 days following notice
- it may be extended by an additional 30 days if additional time is required to address claims for which payment has been made
- it does not include any days where there was a failure in the claims payment and posting system due to exceptional circumstances as defined by regulation
- the related settlement, judgment, award, or other payment must be made during that period, and
- the last statement of reimbursement downloaded during that period and within three (3) business days of the date of the settlement, judgment, award, or other payment shall constitute the final conditional amount subject to recovery by the federal government related to that settlement, judgment, award, or other payment.
Final regulations must be promulgated by October 10, 2013, nine (9) months after date of enactment, the effective date of this provision.
Minimum Values Established
Old Law: The Medicare Lien reimbursement process currently applies even to settlements of minimal value.
New Law: The SMART Act establishes a threshold below which the lien reimbursement and Section 111 reporting obligations do not apply. The threshold will be established each year beginning in 2014. The minimum threshold exception does not apply to settlements concerning alleged ingestion, implantation or exposure (including asbestos).
UPDATED July 31, 2013:
To further explain the minimum values… the SMART Act requires HHS to set a “single monetary compliance threshold” for certain claims, starting on November 15, 2014. The purpose underlying that amendment is to avoid expending resources in seeking to recover conditional payments the value of which is less than the expense necessary to recover them. This is sort of a common sense provision as you will. The “monetary compliance threshold” that the Act contemplates would be a dollar figure that defines the minimum value of a conditional payment for which Medicare could pursue reimbursement without wasting more resources in seeking to recover the payment than the claim itself is worth. The SMART Act requires the Secretary of HHS to set and adjust that minimum threshold figure no later than November 15 each year, starting in 2014. Attorneys should calander this date to learn the threshold for that year.
The monetary compliance threshold does not apply to all conditional payments. More specifically, the monetary compliance threshold applies only to (1) liability TPOC reporting (total payment obligation to the claimant); and (2) conditional payments pertaining to “alleged physical trauma-based incidents,” but not incidents based on alleged ingestion, implantation, or exposure.
§111 Penalty Modification
Old Law: Companies that reported settlements involving Medicare beneficiaries to CMS either late or erroneously were subject to automatic fines of $1,000 per-day, per-claim.
New Law: Such penalties are now discretionary, not automatic. HHS is directed to create “safe harbors” for companies that report in good faith, despite being late or in error. §203, SMART Act.
No SSN or HICN
Old Law: Claims professionals and settlement parties use claimants’ Social Security numbers (SSNs) or Health Insurance Claim Numbers (“Medicare numbers”) to access claimant health records. This situation has obvious and troubling privacy implications.
New Law: Within 18 months, the Secretary of HHS is to change §111 of Mandatory Insurance Reporting to make use of SSNs and Medicare numbers optional rather than required. Medicare beneficiaries are understandably reluctant to provide this information – given the high incidence of identity theft. The SMART Act protects beneficiaries’ sensitive personal information while also reducing professionals’ liability exposure in the event of subsequent beneficiary identity theft. §204, SMART Act.
UPDATE: July 31, 2013
I received a call from a lawyer today asking if SSN’s are still required as his client does not want to give out his SSN. As of this date, SSN’s are still required. The Act provides that CMS must implement this requirement within 18 months of the SMART Act’s enactment, or by the middle of 2014. That deadline is not a firm one, however. The Act permits the Secretary of the Department of Health and Human Services (HHS) (the agency in which CMS operates) to request an extension of that 18-month deadline by “one or more periods up to one year each” if the Secretary believes that eliminating the use of social security numbers and health insurance claim numbers by the operative deadline “threatens patient privacy or the integrity of the secondary payer program[.]” I will keep monitoring for changes but I suggest if you are an attorney and uncertain that you contact the HHS Department.
Three-Year Statute of Limitations
Old Law: The MSP statute permits the government to pursue settling defendants for unsatisfied Medicare Liens in certain circumstances, even after the defendant has paid settlement funds to the plaintiff. Unclear law and inconsistent court rulings left settlement parties without a clear answer on the scope of the statute of limitations for the government to bring an action seeking conditional payment.
New Law: The SMART Act codifies a 2010 U.S. District Court decision – U.S. v. Stricker – which held that the government must file a complaint within three years of receiving notice that a judgment or settlement has been reached. §205, SMART Act.
Full Text of H.R. 1845: http://www.gpo.gov/fdsys/pkg/BILLS-112hr1845rds/pdf/BILLS-112hr1845rds.pdf
A Lawyer’s Timeline Under SMART for Finding Out How Much to Pay Back Medicare
For those lawyer fans of this blog, starting in October 2013, you should follow these rules to obtain a Final Conditional Amount.
- T-120 days to settlement – Send an Expected Settlement Notice to the MSPRC;
- T-115 days to settlement – Check to see if the MSPRC received the Expected Settlement Notice. Everyone knows the MSPRC response, “we don’t have that in the file” or “I don’t see that here.” If you don’t check you might waste the entire process.
- T-55 days to settlement – You should receive notice that the Final Conditional Amount is available for download on the MSPRC website, or more likely, the Medicare Secondary Payer Recovery Portal (MSPRP). If you have not, contact the MSPRC to check the status. Keep in mind the rule states they have 65 days from receipt of your notice – so we will have to keep track of how they define the word receipt. If your case qualifies for “exceptional circumstances” the MSPRC will tell you it needs another 30 days to process the Final Conditional Amount.
- T-25 days to settlement – You should receive notice that your exceptional circumstances request is completed and the Final Conditional Amount is available for download.
- T-3 days to settlement – You must download the Final Conditional Amount from the designated website. If you do so at 4 days to settlement it is apparently invalid and does not constitute a Final amount. If you do so more than 3 days after settlement (we believe after is still okay – the rule uses the word “within”) it is also invalid.
-Published January 31, 2013. Authored by Michelle M. Funkenbusch, St. Louis Trial lawyer
If you know someone in need of a personal injury lawyer, please contact St. Louis Personal Injury Lawyer Michelle Funkenbusch at 314-338-3500 .
© 2013 The Law Offices of Michelle M. Funkenbusch, LLC. All Rights Reserved. These materials may not be reproduced in any way without the written permission of The Law Offices of Michelle M. Funkenbusch, LLC. This blog is designed to provide general information on the topic provided and is posted with the understanding that the publisher is not engaged in rendering any legal or professional services. Although this post and the blog is prepared by a lawyer, it should not be used as a substitute for legal advice. If legal advice is required, the services of The Law Offices of Michelle M. Funkenbusch should be sought privately.
We ALLL have food on the brain the day before Thanksgiving. So Missouri personal injury lawyer, Michelle Funkenbusch sums up Food Hazard/Choking Law for You:
According to Missouri personal injury lawyer, Michelle M. Funkenbusch, if you are injured at a restaurant choking on food hazards (like bones/plastic/toothpicks), Missouri courts follow warranty law to determine liability. The same is true if you purchase a turkey from your local grocery store, cookies from your local scout troop, or candy from a vending machine, or even a beer from your local pub. Specifically, Missouri follows the common law principle that there is an implied warranty as between the retail dealer and the consuming purchaser in the sale of food, including a warranty of freedom from foreign substances which may be injurious to the purchaser. Degouveia v. H.D. Lee Mercantile Co., 231 Mo.App. 447, 100 S.W.2d 336, 339 (1936). A claim for common law implied warranty of fitness for consumption requires that a Plaintiff show: (1) the defendant sold a food substance meant for human(or animal) consumption; (2) the plaintiff (or your animal) ate or drank the food/drink; (3) when the defendant sold the food/drink it was not fit for human(or animal) consumption; and (4) the Plaintiff was damaged as a direct result. See Missouri Approved Instructions (MAI 25.02).
[RANDOM LEGAL FACT OF THE DAY: The MAI is the book of jury instructions relied on by courts to instruct the jury what must be proved in a particular case. The Missouri Supreme Court committee on jury instructions creates this book and it must be reviewed and used in every civil case that goes to trial.]
Grandma’s Food Almost Killed Me!!
What if you are at your Grandma’s house for Thanksgiving and you choke on a foreign substance that you could/would not have inspected in the food? Assuming it was not added to the food by your grandmother (which of course will be a defense of the seller and manufacturer), you may have a case for a personal injury lawyer to review. It doesn’t matter that you didn’t buy the food at a restaurant or store. If the injured party in a choking case was not the purchaser of goods, but is a natural person who is a member of the family or household of the buyer, or was a guest in the buyer’s home, and it was reasonable to expect that such person would consume the food/drink, then the seller or manufacturer can be liable under the Uniform Commercial Code. In other words, even though you lack “privity of contract” you may be able to recover and should seek the counsel of a St. Louis personal injury lawyer. And yes, you could sue Grandma for negligent cooking… but that’s just not nice!
Missouri Personal Injury Case Against the Manufacturer??
If you have sustained personal injury in Missouri as a result of the consumption of a foreign body or substance in a food or beverage sold, you may also, under proper circumstances, maintain an action to recover damages for such injury against the manufacturer of the product, on the ground of breach of an express or implied warranty. In the absence of an express warranty (something actually written on the product or packaging), the law implies that the manufacturer or packer of foods intended for human consumption warrants that his products are fit for human consumption, and that he has used in the selection and preparation of such products the degree of care ordinarily exercised by persons skilled in the business of preparing and packing food for distribution or sale to the general public.
A manufacturer, in the proper factual situation, is held as an “absolute insurer against knowable dangers”, and thus has an incentive to keep abreast of scientific knowledge to keep knowable dangers out of their products. But, in some cases (like in the case of cigarettes), what is knowable can be difficult to prove without a great deal of expense and highly trained personal injury lawyers. Ross v. Phillip Morris, 328 F.2d 3 (United States Court of Appeals Eighth Circuit 1964).
Other Theories a St. Louis Personal Injury Lawyer May File Suit for in A Food Hazard Case
You may also have the right to sue under other theories of personal injury. For example, you may have a claim under the Uniform Commercial Code for breach of an implied warranty for fitness for a particular purpose or breach of implied warranty of merchantability (fitness for an ordinary purpose) in general. You may also have a claim for strict liability for a product defect or for failure to warn. These are complicated claims and require the expertise of an experienced St. Louis personal injury lawyer.
Choking on Bones in the Turkey vs. Glass in the Turkey… why is one a good case and one a bad case?
To have a good case of liability, you usually have to have been injured by something foreign to the food you were eating, but not always. Liability for injuries caused by a substance in food will often depend on whether the substance in question is considered to be “foreign.” Under the so-called foreign-natural test that many other states rely on, there is no liability for injury caused by a substance that are considered “natural” to the food sold. If the object is one that is naturally associated with the type of food in which it is found, it is not considered to be foreign, since the occasional presence of such objects is something to be anticipated by the consumer. Thus, for example, a hardened, crystallized grain of corn has been held not to be foreign to a package of corn flakes, and a bone has been held not to be foreign to a canned food product containing meat of the kind from which the bone came. However, some courts have held that objects which are natural to the type of food involved but which generally are not found in the style of the food as prepared may be deemed to be the equivalent of a foreign substance. Thus, in an action against a packer of canned chicken for injuries sustained from a chicken bone in chicken chow mein served at the plaintiff’s school and made from the defendant’s product, the chicken bone was held to be “something that should not be” in defendant’s product, which defendant had advertised as “boned chicken.” It has also been held in other states that breach of an implied warranty of fitness is shown by proof of a piece of oyster shell in a can of oysters sold by a defendant retailer, even if it appears that shells cannot be entirely eliminated in the canning of oysters.
Several states have rejected the “foreign-natural” test in favor of what is known as the “reasonable expectation” test. This test is based on what is reasonably expected by the consumer in the food as served, not what might be natural to the ingredients of that food prior to its preparation.
The “foreign-natural” test apparently continues to be the rule in most jurisdictions. In states where the “foreign-natural” test is applied, even if an injured plaintiff can establish an otherwise legally sufficient claim of negligence, breach of implied warranty, or strict tort liability, a food processor may be free from liability as a matter of law if the deleterious object or substance in the food is natural to the ingredients of the product. However, in states where the “reasonable expectation” test is the rule, liability might be incurred on any appropriate theory even for a “natural” defect if it is one not reasonably anticipated by the consumer. There appears to be a recent trend among several states toward acceptance of the “reasonable expectation” test.
Missouri has yet to directly adopt either test mentioned above and leaves the fitness for consumption a question for the jury. This grey area of the law is another reason why you should consult with an experienced Missouri personal injury lawyer.
Michelle M. Funkenbusch has handled cases involving plastic in pudding, foreign substances on buffets, rat parts in frozen spinach, lead poisoning, and more. Contact her if you would like to discuss your potential case for free at 314-338-3500.
© 2012 The Law Offices of Michelle M. Funkenbusch, LLC. All Rights Reserved. These materials may not be reproduced in any way without the written permission of The Law Offices of Michelle M. Funkenbusch, LLC. This blog is designed to provide general information on the topic provided and is posted with the understanding that the publisher is not engaged in rendering any legal or professional services. Although this post and the blog is prepared by a lawyer, it should not be used as a substitute for legal advice. If legal advice is required, the services of The Law Offices of Michelle M. Funkenbusch should be sought privately.
Car v. Pedestrian Accidents Safety Checklist for Halloween
According to U.S. Census data, there are about 41 million potential trick-or-treaters between the ages of 5 and 14. Add that statistic to the fact that in 2010, 41 percent of all highway fatalities across the nation on Halloween night (6 p.m. Oct. 31 to 5:59 a.m. Nov. 1) involved a driver or a motorcycle rider with a BAC of .08 or higher, Halloween night requires added attention to safety to all those walking from house to house.
According to statistics from the U.S. Department of Transportation, in four out of six years between 2006 and 2010, more pedestrians under the age of 21 were killed by cars on Oct. 31 than on Oct. 30 or Nov. 1. Taking steps now and remembering them on Halloween night can prevent a pedestrian vs. car accident.
Here a few tips to reduce car v. pedestrian accidents this Halloween from Saint Louis personal injury lawyer Michelle Funkenbusch:
1. Carry a flashlight or glowstick and wear glow-in-the-dark necklaces or attach reflective tape to costumes, wagons, and bags.
2. Loose fitting clothing and oversized shoes can trip a trick-or-treater when crossing the street, so they should practice walking/running in their costume safely. Cut any costumes shorter if necessary.
3. Pirate swords and masks are cool, but are dangerous and masks can obscure vision. Thus, leave the swords at home (or make one from a poster board and aluminum foil) and use face paint instead of masks.
4. Remind kids to cross at crosswalks or at a corner with you. They should also always make eye contact with drivers before stepping into the street and ALWAYS look left, right and left again.
5. For parents and kids, take out the headphones and no texting and walking especially when crossing the road.
6. Avoid the decorative contact lenses — they could blur your vision at night.
7. Many car accidents happen when a vehicle is pulling out of a driveway; kids should always look for cars when walking by a driveway.
8. Stay with a group as you and your children are more visible.
9. In urban areas, make sure children understand they cannot dart out between cars and that they may not see oncoming traffic.
Halloween trick-or-treaters need to be careful, but so do drivers. Drivers need to know that kids will be out of the streets looking for candy and not looking for cars. Avoid a car accident with a child by increasing your look-out for pedestrians. A few extra seconds could prevent a pedestrian vs. car accident!!!
Prepare now to have a safe and enjoyable Halloween. Be safe and watch out for those who aren’t!