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One of the perennial annoyances in personal injury law practice is the need to deal with the Medicare bureaucracy regarding the claims for reimbursement out of personal injury recoveries of a portion of funds paid by Medicare for medical expense.  It’s bad enough to have to send them money, but it’s worse to have to deal with the delay and mindlessness of the bureaucracy. Today I was alerted to a change in the way Medicare deals with those reimbursement claim.

The change in Medicare reimbursement protocol outlined below is only one of many examples of how public and private health care agencies (agencies) are outsourcing their efforts to expose the beneficiaries and attorneys involved in any settlement where the agencies have made conditional payments for injury-related care. These agencies continue to pour substantial resources into the recovery efforts associated with liability and workers compensation settlements.

The Centers for Medicare & Medicaid Services (CMS) awarded a single contract for a national Medicare Secondary Payer Recovery Contractor (MSPRC) to the Chickasaw Nation Industries, Inc.– Administrative Services, LLC (CNI). 

Effective October 2, 2006, CMS transitioned all Medicare Secondary Payer (MSP) recovery workloads, both Group Health Plan (GHP) and non-GHP, to a national MSPRC (and away from the dozen or so contractors that were handling the MSP recovery effort regionally).  The new, national MSPRC will focus its initial efforts on Workers Compensation, No-Fault and Liability cases, including product liability and medical malpractice cases. The lead (regional) recovery contractor with which you have had contact in the past will no longer be responsible for this activity.     

For all new MSP initial recovery demand letters issued on or after the implementation date for the MSPRC (October 2, 2006), you should respond to the entity which issues the recovery demand letter to you. Except for provider, physician, or other supplier MSP recovery claims and a limited number of GHP debts in certain states, this will routinely be the MSPRC.

General Rules:

  • The national MSPRC will have responsibility for all new MSP recovery demand letters issued on or after the implementation date for the MSPRC (October 2, 2006), as well as all subsequent CMS actions on those recovery claims. The two exceptions to this are recovery demand letters issued by the MSP Recovery Audit Contractors (RACs) implemented as a demonstration under the Medicare Modernization Act of 2003 and MSP recovery demand letters issued by the claims processing contractors to providers, physician, and other suppliers. The RACs will continue to have responsibility for certain MSP GHP based recovery demands for the States of California, Florida, and New York. The three MSP RACs are: Diversified Collection Systems (California), Public Consulting Group (Florida), and Public Consulting Group (New York).

    NOTE: The responsibility for all pending MSP recovery cases where a recovery demand letter has not yet been issued will, aside from the two exceptions noted in the preceding paragraph, be the responsibility of the MSPRC. (Please note that a letter providing the amount of Medicare’s conditional payments in connection with a workers’ compensation or liability or no-fault insurance case is not a recovery demand letter.) This responsibility is in line with the MSPRC’s responsibility for the issuance of all new MSP recovery demand letters issued on or after October 2, 2006 (again, with the two exceptions noted in the preceding paragraph).

  • Due to systems issues, the Medicare contractors listed immediately below will continue to have responsibility for all further CMS collection actions with respect to MSP recovery claims where the initial recovery demand letter was issued prior to the implementation date of the MSPRC (October 2, 2006). This includes responsibility for the "Notice of Intent to Refer Debt to the Department of Treasury" where a recovery claim is not repaid timely. The RACs will also continue to have this responsibility for all RAC-initiated MSP recovery claims.
    • Empire – Syracuse NY or Harrisburg PA
    • First Coast Service Options – Jacksonville FL
    • Mutual of Omaha – Omaha NE
    • Palmetto – Augusta GA or Columbia SC or Columbus OH
    • Trailblazer – Denison TX

The MSPRC will have responsibility for all further CMS collection actions for MSP recovery demand letters issued before the implementation date for the MSPRC (October 2, 2006) unless the recovery demand letter was: (1) issued by one of the Medicare contractors listed immediately above; (2) issued by one of the RACs; or (3) issued to a provider, physician, or other supplier.

Once a recovery claim is referred to the Department of the Treasury, the contractor which issued the recovery demand letter and the notice of intent to refer the debt to Treasury will take no further collection action. You should direct any further correspondence to the Department of the Treasury (or its contractor if you have received correspondence from an entity under contract to the Department of the Treasury).

Contact Information for the MSPRC:

MSPRC telephone access became available on October 2, 2006. The number for the MSPRC’s dedicated call center is 1-866-MSP-RC20 (1-866-677-7220), available from 8AM to 8PM Eastern time, Monday through Friday, with the exception of holidays.

The MSPRC is a recovery contractor.   See http://www.cms.hhs.gov/COBGeneralInformation/ for further information about the COBC, including contact information, attorney information, etc. The COBC’s toll- free line is 1-800-999-1118 (TTY/TDD 1-800-318-8782 for the hearing and speech impaired).

The first priority of the MSPRC will be to address previously submitted notices of settlement and to make a formal Medicare demand.  The CMS understands the need to identify Medicare’s final claim and to disburse settlement proceeds.  

The new national recovery contractor will be: MSPRC Liability, P.O. Box 33828, Detroit, MI  48232-3828,Telephone: 1-866-MSP-RC20 (1-866-677-7220).

In a landmark decision released August 31, 2006, the Georgia Court of Appeals has resolved in one case two crucial issues on Uninsured Motorist (UM) insurance coverage:

  • A liability umbrella policy that includes automobile liability must include UM coverage equal to the liability limits unless the UM coverage is affirmatively rejected in writing, notwithstanding an exclusion of UM coverage in the policy. 
  • Renewals of auto liability policies that existed before 7/1/01 that did not include UM coverage must include UM coverage equal to the liability coverage unless UM coverage is affirmatively rejected in writing. The statute requiring UM equal to liability coverage exempted renewals of policies existing before 7/1/01.  The plain language of OCGA § 33-7-11(a)(3) simply “provides that an insurer is not required to increase UM coverage in renewal policies for coverage existing prior to July 1, 2001.”  However, while the amount of UM coverage need not be increased on renewal policies, if there was no UM coverage the exemption does not apply. 

Read the full decision below.

Last month there was a news story about the New Jersey Committee on Attorney Advertising, a panel appointed by the Supreme Court of New Jersey ruling that attorney advertisements that tout listings such as the “Super Lawyers” listings violate professional responsibility rules against ads that compare lawyers’ services or create an “unjustified expectation about results.”  That gave me pause, as it did the marketing folks at every big law firm in Atlanta, since the profile on my web site includes listings in the “Super Lawyers” issue of Atlanta Magazine, “Legal Elite” issue of Georgia Trend magazine, and the Bar Register of Preeminent Lawyers.

However, the Fulton County Daily Report published an article on August 11th reporting an analysis to the effect that,  while Georgia’s ethics rules contain proscriptions against comparative advertisements and ads that create unwarranted expectations, the language in Georgia is more permissive than that found in New Jersey’s ethics rules. The New Jersey rule prohibits as false and misleading any advertisement that “compares the lawyer’s services with other lawyers’ services.” Under Rule 7.1(a)(3) of the Georgia Rules of Professional Conduct, the rule against comparisons does not apply if the comparison “can be factually substantiated.”

The “Super Lawyers,” “Legal Elite,” and “Preeminent Lawyers” lists are all based upon periodic surveys of our peers in the legal profession, and cannot be purchased.  While the methodology is certainly not perfect, neither is it meaningless or factually unsubstantiated.  Therefore, we will continue to include those designations on the web site.

TV lawyer shows never portray the tedious work of reviewing documents, researching law, and analyzing the effect of contracts and insurance policies. The recent decision of the Georgia Court of Appeals in Ryder Integrated Logistics, Inc. v. Bellsouth Tecomms. Inc. illustrates the sometimes mind-numbing work involved in figuring out who pays what after a catastrophic incident such as a major truck wreck. This case involves an indemnification agreement between two companies, a primary insurance policy and an excess insurance policy, with everyone trying to pass the buck. See the full text below.

A friend whose two children both have heart defects recently passed along to me waht he has learned about a couple of obscure options for somewhat affordable health care coveage.
First, the Insurance Commissioner’s Office has an Assigned Risk program. My friend pays $440 per month for family coverage; the plan pays 70% of charges with a $5000 deductible. It does not cover prescriptions, but drugs are counted under the deductible, and they give a discount for prescriptions. My friend has assigned risk coveage through Blue Cross and can go to any doctor.
Second, there is also a program offered through the state called “Care Entree.” Its not health INSURANCE, its Health Discount. Essentially you become the
health insurer, but you only pay that which the insurance company would pay. The Insurance Card you get looks exactly like any other and it uses PCHS (Private Care Health Services) as the plan administrator. Once again, you must agree to have a high deductable, but you only have to pay for those bills that the INSURANCE COMPANY WOULD HAVE TO PAY. That can be a tremendous DISCOUNT. But you must give them enough money to maintain the deductable in THIER ACCOUNT. So that they can pay that amount GUARANTEED. Then you pay that amount.
The plan cost roughly $75 per month, and includes a discount of prescription, Dental, chiropratic etc.

It is well-established Georgia law that insurance contracts are construed to protect the reasonable expectations of the insured. See, e.g., Western Pacific Mut. Ins. Co. v. Davies, 267 Ga.App. 675, 601 S.E.2d 363(2004); Georgia Farm Bureau Mut. Ins. Co. v. Meyers, 249 Ga.App. 322, 324, 548 S.E.2d 67, 69 (2001); Georgia Farm Bureau Mut. Ins. Co. v. Gaster, 248 Ga.App. 198, 201, 546 S.E.2d 30, 31 (2001); Ga. Farm Bureau &c. Ins. Co. v. Huncke, 240 Ga.App. 580, 580-581, 524 S.E.2d 302, 303 (1999); Anderson v. Southern Guar. Ins. Co. of Georgia, 235 Ga.App. 306,309, 508 S.E.2d 726, 730 (1998); American Southern Ins. Co. v. Abbensett, 232 Ga.App. 16, 501 S.E.2d 53 (1998); Home Ins. Co. v. Sunrise Carpet Industries, Inc., 229 Ga.App. 268, 271, 493 S.E.2d 641, 644 (1997); Tifton Machine Works v. Colony Ins. Co., 224 Ga.App. 19, 20, 480 S.E.2d 37 (1996); Cincinnati Ins. Co. v. Davis, 153 Ga.App. 291, 265 S.E.2d 102 (1980); Richards v. Hanover Ins. Co., 250 Ga. 613, 615, 299 S.E.2d 561 (1983).
Where a term of a policy of insurance is susceptible to two or more constructions, even when such multiple constructions are all logical and reasonable, such term is ambiguous and will be strictly construed against the insurer as the drafter and in favor of the insured. O.C.G.A. § 13-2-2(5); Ga. Farm &c. Ins. Co. v. Huncke, supra at 580, 524 S.E.2d 302; Peachtree Cas. Ins. Co. v. Kim, 236 Ga.App. 689, 690, 512 S.E.2d 46 (1999).
Exceptions and exclusions to coverage must be narrowly and strictly construed against the insurer and liberally construed in accordance with the reasonable expectations of the insured to afford coverage. Duncan v. Integon General Ins. Corp., 267 Ga. 646, 482 S.E.2d 325 (1997);Nationwide Mut. Fire Ins. Co. v. Erwin, 240 Ga.App. 816, 817, 525 S.E.2d 393 (1999).