Synergy’s blog brings you the industry’s foremost thought leadership InSights on matters of healthcare lien resolution and Medicare Secondary Payer Compliance. Visit often to discover helpful InSights on important lien resolution compliance issues.
Reprinted with permission from Roger Baron
“Subrogation on personal injury claims by a health insurer was universally prohibited by law when Congress enacted ERISA in 1974. Seizing upon the notion of ERISA preemption, ERISA plans and related insurers have manufactured the right of reimbursement (or subrogation) without regard to the impact on the victims.”
Although most litigation has centered on what qualifies as “appropriate equitable relief,” the U.S. Court of Appeals for the Third Circuit in US Airways, Inc. v. McCutchen, 663 F.3d 671 (3d Cir. Pa. 2011), addressed whether such relief is limited by certain equitable defenses. While the Third Circuit’s approach may be considered novel (at least until adopted by other courts), it presently allows equitable principles to override express plan language when justified by the necessities of the particular case. For attorneys in other jurisdictions representing severely injured beneficiaries against self-funded ERISA liens with strong plan language, referencing the Third Circuit’s logic may prove beneficial.
Ingenix v. Ham, a Florida 2nd DCA opinion, applies 768.76(4) instead of the contract in a reimbursement action involving UnitedHealthcare (non-ERISA).
Outsourcing of lien resolution needs for a law firm can make for happier clients and a better bottom line.
The MSPRC announced a new option to self calculate a conditional payment amount to submit for approval if the settlement is $25,000 or less.
MSPRC has provided instructions on how to elect the fixed percentage option for conditional payment resolution.
MSPRC to institute self service phone line.
On 9/29/11, CMS issued a memorandum indicating there is no need for a liability Medicare set aside and that its interests would be satisfied if the treating physician certifies in writing that treatment for the alleged injury related to the liability insurance has been completed as of the date of settlement.
In the first memo coming from CMS HQ regarding Liability Medicare Set Asides, Charlotte Benson, Acting Director Financial Services Group for CMS, gives us an exception to the need to create a set aside. According to the memo, a liability Medicare set aside isn’t necessary when the Medicare beneficiary’s treating physician certifies in writing that all of the care related to the claimed injury has been completed as of the date of the settlement.