Blog

CLASSIC LIST

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22/May/2024

The Centers for Medicare & Medicaid Services (CMS) has released the Self-Administration Toolkit for WCMSAs version 1.5 on May 15, 2024.  The Toolkit replaces Version 1.4 which was released on July 3, 2023.

To download the new Self-Administration Toolkit for WCMSA Version 1.5 click here.

Self-Administration With Additional Help

For injured parties who are considering self-administration, but who also want additional consultation on the process, Medivest provides a Self-Administration Kit. With purchase of the Medivest Medicare Set-Aside Self-Administration Kit, the injured person will receive a one-hour consultation on the proper administration of a Medicare Set-Aside account, covering topics including:

    • Where to deposit and hold Medicare Set-aside funds
    • Which expenses are allowed to be paid from a Medicare Set-Aside account
    • What rates must be used to negotiate and pay for expenses
    • How to annually report the Medicare Set-aside to the CMS
    • What to do if the MSA funds exhaust temporarily or permanently
    • How to discuss a Medicare set-aside with a medical provider
    • What are the tax implications of interest earned on Medicare Set-Aside funds

     

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions about self administration, professional administration or anything else regarding rules and recommendations from CMS, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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02/Apr/2024

The Centers for Medicare & Medicaid Services (CMS) released a revised Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (“Reference Guide”) Version 4.0 on April 1, 2024. This Reference Guide replaces Version 3.9 which was released on May 15, 2023. There are a few notable changes when comparing the two Reference Guides.   

Changes in This Version 4.0 of this Guide Include the Following Changes:

  • Instruction specific to beneficiaries has been added to encourage them to use their Medicare.gov access to the portal for the most efficient method of submitting attestations (Sections 11.1.1 and 17.5). This user-friendly mechanism which allows CMS to gain potentially more MSA spending information than it has received via traditional mailing, may lead to CMS denying more future medical claims or potentially considering whether recovery of future medical payments that slipped through the cracks is viable. 
  • The CDC Life Table link was updated (10.3) – available to view here.

 

To download the new WCMSA Reference Guide v4.0 click hereThis guide reflects information compiled from all WCMSA Regional Office (RO) Memoranda issued by CMS, from information provided on the CMS website, from information provided by the Workers Compensation Review Contractor (WCRC), and from the CMS WCMSA Operating Rules. The intent of this reference guide is to consolidate and supplant all historical memoranda in a single point of reference. Please discontinue the reference of prior documents.

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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31/Jan/2024

The January 18th, 2024 webinar hosted by Centers for Medicare & Medicaid Services (CMS) entitled Medicare Secondary Payer and Certain Civil Money Penalties (Non-Group Health Plan) is now available in the Download section of the What’s New page on CMS.gov. The webinar can be viewed in its entirety, or you may download the materials covered in PDF format by clicking here.   

Medivest will continue to monitor news and updates from CMS and will keep its readers up to date when important announcements are made. For questions regarding the information presented in this webinar or any other recent CMS updates, please reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467. 

 


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22/Jan/2024

On January 10, 2024, the U.S. Department of Labor published a final rule, revising its guidance to employers and workers to help determine if a worker qualifies as an employee or an independent contractor (IC) under the Fair Labor Standards Act (FLSA).  The final ruling explains that the economic reality test is comprised of six-factors that are a guide to conduct the totality-of-the circumstances analysis to determine economic dependence. The new ruling takes effect March 11, 2024. To view the final ruling, click here 

Misclassification Issues 

Employers need to distinguish between employees and independent contractors when considering eligibility for workers’ compensation. Correctly distinguishing between employees and independent contractors is crucial for legal compliance, cost management, liability avoidance, and ensuring workers receive the appropriate benefits and protections. Misclassification can have significant financial and legal consequences for employers. 

What is the Economic Realities Test?  

The US Department of Labor uses an economic realities test to help employers comply with the law, reduce the risk of employee misclassification, and to help determine if a worker is classified as an independent contractor or as an employee. This test consists of six-factors that are all weighed against each other. All factors should be considered.  No single factor determines a worker’s status.  No one factor or combination of factors is more important than the other factors.  This test considers the totality of the circumstances of the working relationship. Below are the six (6) factors. 

  1. Opportunity for profit or loss depending on managerial skill, 
  2. Investments by the worker and the employer, 
  3. Permanence of the work relationship, 
  4. Nature and degree of control, 
  5. Whether the work performed is integral to the employer’s business  
  6. Skill and initiative 

 

About Medivest 

Since 1996 Medivest has been helping our clients navigate the complexities of MSP compliance.  We offer settlement solutions for workers’ compensation and liability settlements. Count on Medivest to help keep you up to date with the constant updates regarding Federal Register rulings, Medicare Secondary Payer legislation and changes related to CMS’s enforcement of the Medicare Secondary Payer.  For questions, feel free to reach out to a Medivest representative in your area by clicking here or call us direct at 877.725.2467. 

 


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08/Jan/2024

It is getting close to that time of year when mailboxes begin to receive W-2 statements and 1099-INT statements.  If an injured individual has either a Self-Administered Medicare Set-Aside (MSA) account or a Professionally-Administered MSA account, the individual will be sent a 1099-INT by January 31st and a copy will be filed with the IRS. The 1099-INT shows interest earned in the account during the previous tax year.
Liability and Workers Compensations cases should follow the Workers Compensation Medicare Set-Aside (WCMSA)Reference Guide, until CMS publishes a Liability Medicare Set-Aside (LMSA) Reference Guide.  Until then, the WCMSA Reference Guide should be considered a single point of reference for Liability and Workers Compensation cases. To download the WCMSA Reference Guide Version 3.8, Dated November 14, 2022, click here.

 

What the WCMSA Reference Guide states:

  • MSA funds must be placed in an interest-bearing account that is separate from the individual’s personal savings and checking accounts.
  • The interest must be deposited into the MSA account to be used for MSA-covered expenses.
  • You can use the MSA account to pay for the income tax on the interest income.
For further clarification regarding how the individual can pay for the taxes from the interest incomed earned in their account, refer to the CMS Memo Dated July 11, 2005, Subject:  Medicare Secondary Payer (MPS) – Workers’ Compensation (WC) Additional Frequency Asked Questions.
“Q6. Treatment of Taxable Interest Income Earned on a WCMSA – If I receive a Form 1099-INT for the interest income earned on my WCMSA account, may I charge the income tax on that amount against the WCMSA?
A6. Assuming that there is adequate documentation for the amount of incremental tax that the claimant must pay for the interest earned on this set-aside account, the claimant or his/her administrator may withdraw an amount equal to the additional tax as a “cost that is directly related to the account” to cover the additional tax liability. Such documentation should be submitted along with the annual accounting.”

 

How Medivest Handles the 1099-INT:

Medivest will advise the Member to prepare his/her tax return two ways to determine the increased income tax burden, if any:
  1. Include the MSA interest income in the income tax return
  2. Exclude the MSA interest income in the income tax return
In other words, if the Member must pay the IRS an increased income tax amount as a result of the interest earned from their MSA account, the additional income tax burden can be paid from the MSA account.  This is considered a cost associated with having the MSA account and CMS allows this expense to be paid from the MSA account.  Once a year, Medivest will send CMS an attestation for every applicable professionally-administered MSA account.  Any MSA reimbursement of the additional income tax burden will be included in this attestation.

 

Answers to Common Questions

Question 1.  If I am taxed on the earned interest, why can’t I have it?
Answer 1.  CMS’ guidelines state that Medicare Set-Aside funds place must be placed into an interest-bearing account and are to be used for covered medical expenses.
Question 2.  Why do I have to report the earned interest to the IRS?
Answer 2.   Per IRS guidelines, all interest income is taxable, unless specifically excluded.
Question 3.  Isn’t my injury settlement tax-exempt?
Answer 3.  Any compensation you receive from a settlement because of physical injuries or sickness is not taxable.   However, the interest earned after the settlement occurs is taxable.

 

Best Practices

Medivest’s highly trained representatives can help you figure out if Medicare may have an interest in your settlement. We assist all settling parties to navigate the MSP complexities and provide you with cost-saving strategies for your settlement. For questions about your account or setting up a new professional administration account please contact us here.

 


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20/Dec/2023

You have settled your injury case and have decided to self-administer your Medicare set-aside (MSA) arrangement. Whether you are just beginning to embark on this journey or if you have been self-administering your account for a while and need a refresher, here are a few tips you should know. These tips can help you navigate through this complicated process. They will ensure that you won’t jeopardize your Medicare benefits, help you preserve your MSA funds so they will be there when you need them the most, and will help you prepare to administer your MSA throughout 2024 and beyond.  

 

Helpful Self-Administration Tips:  

Set Up your MSA Correctly

  • Know how your Medicare Set-Aside account will be funded. There are two ways to fund MSA account either with a lump-sum payment or a structured annuity. If your settlement says that it will be funded as a lump sum, one check will be issued. Or, if your settlement says that it will be funded with a structured annuity, then an initial deposit is made to establish the account, followed by annual deposits.  
  • Open a separate bank account to deposit your MSA funds. Do not co-mingle your MSA funds with your personal funds.   
  • Deposit your MSA funds into an interest-bearing bank account, insured by FDIC.  
  • It is recommended to find a bank that does not charge fees when you have a low balance and preferably to find an account that you could write checks on.  

 

Learn the Process and Develop Good Habits Now

  • Keep your settlement paperwork in a safe place.  
  • Know your date of settlement. Any expense that is injury related, Medicare covered, and has occurred after the date of settlement can be paid out of your Self-Administered Medicare Set-Aside account.  
  • Only use the MSA funds from your account to pay for Medicare covered medical treatment and prescription costs related to your injury, even if you are not yet enrolled in Medicare.  
  • Keep accurate records of the expenses you’ve paid out of your account. You will not submit these records annually, but Medicare may request these records as proof that you are using the account correctly.    
    • Transaction date 
    • Check number (if any, or transaction number if present) 
    • “Payable to” or health care provider name  
    • Date of service 
    • Description (procedure, service, or item received; deposit; interest; other allowable expense) 
    • Amount paid 
    • Any deposit amount 
    • Account balance 
    • Keep itemized receipts 
    • Banks statements 
    • Tax records 
  • You will need to send an annual attestation form every year to Medicare, no later than 30 days after the anniversary date of your Workers Compensation settlement regarding funds remaining in the account after expenses have been paid.  

 

Know What Expenses Your MSA Covers

  • MSA account can be used to pay for the following: 
    • Cost of copying documents 
    • Mailing fees/postage 
    • Any banking fees related to the account 
    • Income tax on interest income from the account
  • You may not use the MSA account to pay for:  
    • Fees for trustees, custodians, or other professionals hired to help administer the account 
    • Expenses for administration of the MSA (other than those listed above) 
    • Attorney costs for establishing the MSA 
    • Medicare premiums, co-payments and deductibles

 

What to Do When Your MSA is Exhausted or Depleted

  • If you are a Medicare beneficiary and your funds have been depleted, you can forward your bills to Medicare for payment as long as the expense is Medicare covered and injury related. 
  • If you are not Medicare covered and your funds have been depleted, you will need to coordinate benefits with your other health insurance providers or pay out of pocket. 
  • When your account is permanently exhausted or depleted, which means there is no money left in the account and there will be no future deposits, you will need to submit within 60 days of the date your account is depleted a final attestation letter stating the account is ‘completely exhausted’.    
  • Notify Medicare’s Benefits Coordination & Recovery Center (BCRC) if death has occurred before the WCMSA is permanently exhausted.   
  • If you lose your Medicare entitlement, you are not entitled to release the MSA funds. 

 

What Happens it Self-Administering is Too Difficult?

If learning how to self-administer your MSA on your own is too difficult to navigate, contact Medivest to learn more about our Self-Administration Kit with assistance. Or, if you’re interested in a more hands-off solution, Medivest Professional Administration Services can remove potential risks and the cumbersome tasks associated with administrating your Medicare Set-Aside funds, and in most cases can even stretch the lifespan of a MSA. Please call us at 877.725.2467 or reach out to us here. 


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25/Jul/2023

On July 19, 2023, the Centers for Medicare & Medicaid Services (CMS) released their list of the Top 10 Section 111 Non-Group Health Plan Reporting Errors between January 1 – June 30, 2023. The chart with the list of errors and their rank can be viewed below. A downloadable PDF of this chart cane be found at the CMS website here.

Medivest will continue to monitor news and updates from CMS, and will keep its readers up to date when important announcements are made. For questions about this chart or any other recent updates, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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07/Jun/2023

On June 5, 2023 Centers for Medicare & Medicaid Services (CMS) updated the MMSEA Section 111 NGHP User Guide version 7.2. It has been posted to the NGHP User Guide page on CMS.gov.  The NGHP User Guide version 7.2 replaces Version 7.1 which was released on April 4, 2023.

To download the updated MMSEA Section 111 NGHP User Guide 7.2 click here.

Who Must Report

An organization that must report under Section 111 is referred to as a responsible reporting entity (RRE). In general terms, NGHP RREs include liability insurers, no-fault insurers, and workers’ compensation plans and insurers. RREs may also be organizations that are self-insured with respect to liability insurance, no-fault insurance, and workers’ compensation.

What’s New – 7.2 Version

New information regarding Mandatory Insurer Reporting for Non-Group Health Plans (NGHPs) and NGHP Town Hall Events is posted here as it becomes available.

MMSEA III – June 6, 2023 – NGHP User Guide 7.2 Version Updates

    1. Chapter I: Introduction and Overview
    2. Chapter II: Registration Procedures
    3. Chapter III: Policy Guidance
    4. Chapter IV: Technical Information
    5. Chapter V: Appendices
    6. 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting NGHP Entities, Version 5.8
  1. Chapter I: Introduction and Overview – Updates

The updates listed below have been made to the Introduction and Overview Chapter Version 7.2 of the NGHP User Guide. As indicated on prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. There are no version updates to this chapter.

  1. Chapter II: Registration Procedures – Updates

The update listed below has been made to the Registration Procedures Chapter Version 7.2 of the NGHP User Guide. As indicated on prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. There are no version updates to this chapter.

  1. Chapter III: Policy Guidance – Updates

The updates listed below have been made to the Policy Guidance Chapter Version 7.2 of the NGHP User Guide. As indicated on prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. The guidance on determining the ORM termination date based on a physician statement has been clarified (Section 6.3.2). Guidance on what triggers the need to report ORM has been clarified (Sections 6.3 and 6.5.1.1).

  1. Chapter IV: Technical Information – Updates

The updates listed below have been made to the Technical Information Chapter Version 7.2 of the NGHP User Guide. As indicated on prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide, as necessary. The NGHP Unsolicited Response File format has been simplified, and filename formats have been added (Section 7.5 and Chapter 10). For liability claims, it is now optional to report ‘NOINJ’ codes in certain circumstances (Section 6.2.5.2).

  1. Chapter 5: Appendices – Updates

The updates listed below have been made to the Appendices Chapter Version 7.2 of the NGHP User Guide. As indicated on prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. The end-of-line character has been clarified for files using HEW software (Appendix E). The NGHP Unsolicited Response File layout has been simplified (Appendix F).

  1. 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting NGHP Entities, Version 5.8 – Changes for this Release

The updates listed below have been made to the Appendices Chapter Version 7.2 of the NGHP User Guide. As indicated on prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. The end-of-line character has been clarified for files using HEW software (Appendix E). The NGHP Unsolicited Response File layout has been simplified (Appendix F).

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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31/May/2023

The Centers for Medicare & Medicaid Services (CMS) released a revised Workers’ Compensation Medicare Set-Aside Arrangement (WCMSAReference Guide (“Reference Guide”) Version 3.9 on May 15, 2023. This Reference Guide replaces Version 3.8 which was released on November 14, 2022. There are a few notable changes when comparing the two Reference Guides.

To download the new WCMSA Reference Guide v3.9 Click Here.

CMS’s Version 3.9 Reference Guide

Section 1.1 includes the following changes:

    • All WC letters currently signed with CMS’ Director of Financial Services Group name and signature image have been updated to reflect the current CMS customer service contact information (Appendix 5).
    • The CMS Regional Offices are no longer responsible for approving initial determinations. Process language and contact information have been updated throughout the guide (Sections 9.0, 9.4.6, 9.5, and 18.0, and Appendix 5).
    • Clarification has been provided regarding intrathecal pump, spinal cord stimulator, and peripheral nerve stimulator replacement frequency calculation (Section 9.4.5).
    • The maximum time limit for eligibility has been removed from the Amended Review process (Section 16.3).
    • The 94585 ZIP code has been added to the Walnut Creek Medical Center in the table listing major medical centers (Appendix 7).
    • The CDC Life Table link was updated (Section 10.3)

 

Appendix 5: CMS Customer Service Contact Signature Image Updated to All WC Letters

All WC letters currently signed with CMS’ Director of Financial Services Group name and signature image have been updated to reflect the current CMS customer service contact information (Appendix 5).  The following letters have been updated:

  • Approval Letter
  • Zero Set-Aside Letter
  • Below Threshold Letter
  • Beneficiary Below Threshold Letter
  • Development Letter
  • Closeout Letter

 

CMS Regional Offices No Longer Responsible for Approving Initial Determinations

The CMS Regional Offices are no longer responsible for approving initial determinations. Process language and contact information have been updated throughout the guide (Sections 9.0, 9.4.6, 9.5, and 18.0, and Appendix 5). Clarification has been provided regarding intrathecal pump, spinal cord stimulator, and peripheral nerve stimulator replacement frequency calculation (Section 9.4.5). The maximum time limit for eligibility has been removed from the Amended Review process (Section 16.3). The 94585 ZIP code has been added to the Walnut Creek Medical Center in the table listing major medical centers (Appendix 7). The CDC Life Table link was updated (Section 10.3).

9.0 Updates: Process Language and Contract Information

WCMSA Submission Process Overview
  • 3.8 version: The WCRC applies the CMS’ criteria in reviewing proposals and forwards the proposals along with a recommendation on the appropriate funding amount to the assigned CMS Regional Office (RO) for a final determination.
  • 3.9 version: The WCRC applies CMS’ criteria in reviewing proposals and making a determination, forwards the final determination on the appropriate funding amount to CMS.

 

9.5 Updates: Regional Office Receipt to Determinations

  • 3.8 version: Regional Office Receipt

When the WCRC completes its review and recommendation, the case is sent to the RO assigned to the case based on the claimant’s state of residence and CMS’ state and region logic. Although the RO assignment is based on the state of residence of the beneficiary, a case may be transferred from one RO to another based on the case’s legal state of venue, or because the RO that the case was originally assigned to no longer processes WCMSA cases. When the RO receives the case, they review the WCRC recommendation and make a final determination in the case.

  • 3.9 version: Determinations

*The update pertains to cases may not progress to approvals for a number of reasons, basically switches the responsibility from the Regional Office (RO) over to the Workers’ Compensation Review Contractor (WCRC).

New Language Added
      • The WCRC may determine that the case should be closed. This can happen for a number of reasons, included: the parties are not longer settling, the case should be Black Lung instead of WC, the case is Liability rather than WC case, or the submitted has failed to submit necessary information after repeated development requests.  The submitted is notified of the case closure for ineligible cases closed for insufficient information.
      • When the WCRC completes its review and recommendation, CMS issues its determination in the form of an Approval letter to the submitter with copies sent to any eligible parties. Then the case is transferred to the Consolidated Regional Office to await receipt of the settlement documents so that the case may move to Final Determination/Case Completion.

     

9.6 Updates:  From Final Determination to Case Completion

  • 3.8 version: Final Determination

If the claimant is living, the case meets workload review threshold, any needed development has been received, and the case is not closed for other reasons, the RO reviews the WCRC’s recommendation and makes a determination as to the final CMS-approved WCMSA amount.

  • 3.9 version: Case Completion

If the claimant is living, the case meets workload review thresholds, any needed development has been received, the case is not closed for other reasons, and the WCRC’s recommendations have been provided, then an approval letter is issued to the submitter with a determination as to the final CMS-approved WCMSA amount.

9.4.5 Clarifications: Medical Review Guidelines

Intrathecal Pumps
  • 3.8 version: Permanent placement of IT pump devices are included every 7 years: the claimant’s life expectancy is divided by 7, decimals are dropped, and the whole number Is used for determining replacement over the life expectancy.
  • 3.9 version: CMS policy assumes that a beneficiary would obtain the prescribed therapy within the first year following settlement if not already placed, or at the next routine interval for replacement.  The routine replacement interval for IT pump devices is every seven years from the most recent placement date.  If the IT pump is not already placed, one year is removed from the life expectancy before the replacement calculation occurs to account for that initial replacement.  To calculate the number of replacements, the claimant’s life expectancy less the number of years from the most recent placement date is divided by seven, decimals are dropped, and the whole number is used for determining replacement over the life expectancy.
Examples:
        • Beneficiary life expectancy is 21 years and no IT pump is yet placed. Take the 21 years, subtract one year for the initial placement, divide the remainder by seven, and use the whole number with that result.
        • (21-1)/7 = 20/7 = 2.86
        • One initial placement is needed, plus 2 replacements.
        • Beneficiary life expectancy is 12 years and an IT pump was placed three years prior. Take the 12 years, subtract four years for the most recent placement, divide the remainder by seven, and use the whole number with that result.
        • (12-4)/7 = 8/7 = 1.14 One replacement is needed.

         

 Spinal Cord Stimulators
  • 3.8 version: Permanent placements of SCS devices are included every 7 years for non-rechargeable and every 9 years for rechargeable: the claimant’s life expectancy is divided by the frequency of replacement of type, decimals are dropped, and the whole number is used for determining replacement over the life expectancy.
  • 3.9 version: CMS policy assumes that a beneficiary would obtain the prescribed therapy within the first year following settlement if not already placed, or at the next routine interval for replacement.  The routine replacement interval for SCS devices is every seven years for non-rechargeable and every nine years for rechargeable from the most recent placement date.  If the SCS is not already place, one year is removed from the life expectance before replacement calculation occurs to account for that initial placement. To calculate the number of replacements, the claimant’s life expectancy less the number of years from the most recent placement date is divided by seven (or nice, depending on the unit type), decimals are dropped, and the whole number is used for determining replacement over the life expectancy.
Examples:
        • Beneficiary life expectancy is 33 years and no SCS is yet placed, but a non-rechargeable unit is appropriate. Take the 33 years, subtract one year for the initial placement, divide the remainder by seven, and use the whole number with that result.
        • (33-1)/7 = 32/7 = 4.57
        • One initial placement is needed, and 4 replacements are needed.
        • Beneficiary life expectancy is 17 years, subtract six years for the most recent placement, divide the remainder by seven, and use the whole number with that result.
        • (17-6)/7 = 11/7 = 1.57
        • One replacement is needed.

         

Pricing for Peripheral Nerve Stimulator (PNS) Surgery

(PNS) Surgery PNS surgery involves the placement of an electrode(s) in the direct vicinity of a specific peripheral nerve located outside the brain or spinal cord, thereby directly stimulating the painful peripheral nerve. CMS policy assumes that a beneficiary would obtain the prescribed therapy within the first year following settlement if not already placed, or at the next routine interval for replacement. The routine replacement interval for PNS devices is every seven years for non-rechargeable and every nine years for rechargeable from the most recent placement date. If the PNS is not already placed, one year is removed from the life expectancy before replacement calculation occurs to account for that initial placement. To calculate the number of replacements, the claimant’s life expectancy less the number of years from the most recent placement date is divided by seven (or nine, depending on unit type), decimals are dropped, and the whole number is used for determining replacement over the life expectancy. PNS replacement calculations are done the same as for SCS surgeries.

Examples:
        • Beneficiary life expectancy is 27 years and no PNS is yet placed, but a non-rechargeable unit is appropriate. Take the 21 years, subtract one year for the initial placement, divide the remainder by seven, and use the whole number with that result.
        • (27-1)/7 = 26/7 = 3.71
        • One initial placement is needed, and three replacements are needed.
        • Beneficiary life expectancy is 15 years and a rechargeable PNS was placed two years prior. Take the 15 years, subtract two years for the most recent placement, divide the remainder by seven, and use the whole number with that result. (15-2)/7 = 13/7 = 1.86
        • One replacement is needed.
        • Surgery pricing includes physician fees, facility fees, and anesthesia fees, if applicable.
        • Physician fees: CPT codes are identified and priced based on the appropriate state fee schedule (or usual and customary charges from a state).
            • 64555, Percutaneous implantation of neurostimulator electrode; peripheral nerve
            • 64555, Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
            • 64590, Insertion or replacement of peripheral or gastric neurostimulator generator
            • 01941, Anesthesia
        • Facility fee: Generally, this procedure is handled in an outpatient setting. The appropriate APC should be included based upon surgery type.
            • 5462, Stimulator Trial
            • 5464, Stimulator Placement
            • 5464, Stimulator Replacement Consider the number of leads to be used.
        • Analysis Services: CPT 96972 can be billed every 30 days and more frequently in the first month. It should be priced four times in the first 30 days, monthly for the first year, and twice a year after the first year.
            • 95972 – Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular, except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming.
        • Anesthesia fee: The anesthesia fee is calculated by multiplying the time-value unit by a base value. The time-value unit is the reasonable time for a procedure. The base value is either established by the fee schedule, or by Medicare and conversion factors.
        • Trials: If an associated trial takes place before the surgery, the trial is assumed to be successful and included with the cost of surgery. PNS is one time after trial, if successful. If a trial fails, a repeat trial is usually not appropriate unless there are extenuating circumstances that led to the trial failure (equipment malfunction, early lead migration, etc.), technological advances, or an alternative neuromodulary technique that may lead to a more successful second trial (see LCD L34328). If submitters give a detailed breakdown of their proposed surgery prices, the reviewer will consider the proposed amounts.

         

16.3 Updates: Amended Review

  • 3.8 version: CMS has issued a conditional approval/approved amount at least 12 but no more that 72 months prior.
  • 3.9 version: CMS has issued a conditional approval/approved amount at least 12 months prior.

 

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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27/Feb/2023

In what has become a familiar sight for Medicare Secondary Payer (MSP) rule watchers, CMS has released a notice to delay a proposed rule. This time it is in regard to Section 111 civil money penalty regulations that were announced three years ago. The final rule has now been pushed back for an additional year.

 

The Proposed Rule

On February 18, 2020, the Proposed Rule regarding MSP and Certain Civil Monetary Penalties (CMPs) 85 Fed. Reg. 8793 was released, and the agency opened a public comment period to allow for feedback until April 20, 2020. CMS was expected to complete and release its final rule within the standard three-year period for release, which in this instance would be sometime on or before February 2023.  The proposed rule can be found here.

 

Section 111 Background

The Section 111 penalty provision, which allows the Centers for Medicare and Medicaid Services (CMS) to impose Civil Monetary Penalties against NGHP RREs as follows:

    • Up to $1,000 for each day of noncompliance with respect to each claimant.
    • Up to $1,000 penalty amount will be adjusted annually for inflation under 45 CFR part 102.
    • Current maximum penalty amount as adjusted for inflation is $1,247.
    • As part of its NPRM, CMS outlines proposed situations when it could impose a CMP, along with specific instances when it would not impose a CMP.

     

    Summary

    This final proposed rule specifies how and when CMS must calculate and impose civil money penalties (CMPs) when group health plan (GHP) and non-group health plan (NGHP) responsible reporting entities (RREs) fail to meet their MSP reporting obligations in any one or more of the following ways: When RREs fail to register and report as required by MSP reporting requirements; when RREs report as required, but report in a manner that exceeds error tolerances established by the Secretary of the Department of Health and Human Services (the Secretary); when RREs contradict the information the RREs have reported when CMS attempts to recover its payments from these RREs. This proposed rule would also establish CMP amounts and circumstances under which CMPs would and would not be imposed.

     

    Extension Timeline for Publication of Final Rule

    On February 18, 2023 the Federal Register published the Medicare Secondary Payer of Certain Civil Money Penalties, Extension of Timeline of Final Rule.  Along with the filing, CMS admitted it was “not able to meet the initial targeted 3-year timeline for publication due to delays related to the need for additional, time-consuming data analysis resulting from public inquiry.” The agency has extended the timeline for another year and has until February 18, 2024 to release the announcement.  Click here to read the memo.

     

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