CMS Reporting Penalty Will Be $1000 per Claim per Day

$1000 per Claim per Day Effective January 1, 2011

I normally do not like “scare-tactics” as a way to get our client’s attention.  However, I am making an exception to that philosophy in deference to the CMS upcoming deadline for Mandatory Insurer Reporting that will take effect on January 1, 2011.

John Miano is Gould and Lamb’s Manager of Reporting Services.  He is so passionate about his job and making sure our clients do not get caught in the CMS reporting penalty for non-compliance that I have to share a recent alarming article he wrote:

Written by John Miano, Manager of Reporting Services, Gould and Lamb

You’ve been here before; ready to commit but there’s concern. Your new partner is complex, demanding and you’ve been left waiting. You have made several attempts at getting his/her attention but the timing has never been right. Your partner just keeps ignoring you. Your peers tell you the relationship will never work…just forget about it.

Does this sound like a new episode of Jersey Shore?  Maybe, but it most likely describes the relationship of our industry with CMS reporting requirements for MMSEA Section 111 and the deadline for MIR compliance changes going into effect on January 1, 2011.

Gould and Lamb and our clients have been ready to commit to providing data for MIR in the past, only to have CMS push the mandate back, alter the rules and change specifications.

Even with these CMS delays, the Quarter 1 mandate is real. A sufficient number of Responsible Reporting Entities – RRE’s have provided data to CMS voluntarily to indicate that the industry is prepared.

Less than 30 days to have production data to Gould and Lamb for October 18th Query Input Deadline

What this means for Gould and Lamb’s MIR customers, RRE’s and Claims Administrators NOT currently in production is that it’s time to wrap up testing and move to production NOW!.

Medicare Eligibility of the injured party is the first of many criteria for MIR for CMS reporting. Therefore, Query Input files must be submitted to and Query Responses received from CMS timely to ensure sufficient preparation of MIR claim record data.

The query input file requires a small number of basic data such as the RRE ID, the injured party’s first name, last name, gender, date of birth and social security number. The injured party information should be as it appears on his or hers Social Security of Medicare Card to ensure the best chance of receiving an accurate response from CMS.

In short, a Reporting Group 1 RRE must have production data to Gould & Lamb by October 18, 2010 to ensure sufficient time for the Query Response and preparation of data for January 1, 2011 MIR reporting date. The non-compliance CMS reporting penalty is high – $1,000 per claim per day.

Time is short, do NOT get caught in CMS’s $1,000 per claim per day reporting penalty. Contact your Client Liaison Specialist at Gould and Lamb today at Onesource.support@gouldandlamb.com or 866.672.3453 Ext. 1122.


Click Here to Download the MSP Compliance Protocols User Guide from Gould and Lamb
Download Gould and Lamb’s Medicare Secondary Payer Compliance and Protocols User Guide

Download the MSP Compliance Protocols user guide today!

Gould and Lamb on Mandatory Insurer Reporting Panel at Conference

Gould and Lamb Sponsors Florida Workers’ Compensation Conference

The 65th Annual Florida Workers’ Compensation Educational Conference and 22nd Annual Safety and Health Conference will take place at the Orlando World Center Marriott August 15-18, 2010. Gould and Lamb, in addition to sponsoring and exhibiting at the event, will participate in two panel discussions on Wednesday, August 18.

Kip Daniels, Executive Vice President of Strategic Services, will be a part of a panel discussion on Mandatory Insurer Reporting (MIR) beginning at 9:00 am, and I will be a part of a panel discussing Medicare Set Asides and liability claims at 2:30 pm.

Join Us for Florida’s 65th Annual Workers’ Compensation Educational Conference in Orlando

The Mandatory Insurer Reporting panel will explore the current and projected MIR landscape, the realities of Section 111 Reporting and the State Children’s Health Insurance Program (SCHIP) requirements. Topics will include which entities are required to report, what information must be reported, penalties for non compliance and incomplete reporting and the effect of MIR on workers’ compensation and tort litigants.

The Liability MSA panel will focus on taking Medicare’s interest into account in liability cases, the current state of liability practice, potential MSA thresholds, CMS guidance on liability cases and practice tips for litigants and carriers.

Mandatory Insurer Reporting Experts

Both panels are comprised of the current experts in the field of Mandatory Insurer Reporting and Medicare Secondary Payer Compliance and include Roy Franco of Safeway, Inc. and the Medicare Advocacy Recovery Coalition as well as executives and attorneys well versed in Medicare intricacies and policies. We look forward to sharing our views and insights with the attendees and are pleased to participate at this informative event.


Click Here to Download the MSP Compliance Protocols User Guide from Gould and Lamb
Download Gould and Lamb’s Medicare Secondary Payer Compliance and Protocols User Guide

Download the MSP Compliance Protocols user guide today!

Gould and Lamb Announces Release of their Liability Guidelines

Liability Guidelines and Case Settlement Protocols Now Available

Gould and Lamb is pleased to announce the release of settlement guidelines and protocols for use in the resolution of general liability cases.

The Guidelines, prepared for our clients outside of the workers’ compensation arena, include strategies for resolving liability claims while ensuring compliance with the Medicare Secondary Payer Statute and the mandate to protect Medicare’s interests. While there is heated debate regarding the applicability of Medicare Set Aside allocations in liability cases, G & L believes that Medicare Secondary Payer Statute can and will be construed to require the use of allocations in liability cases.

Despite which side of the debate you subscribe to, Gould and Lamb has provided the guidelines for those clients who believe that the MSP Statute places an affirmative burden on them to consider Medicare’s interests for both Conditional Payment resolution and for future medical care. The guidelines include settlement language for all scenarios encountered in liability cases including options for creating settlement allocations with or without submission to CMS.

Additionally, Conditional Payment resolution strategies are included with specific language crafted to ensure MSP Compliance. G & L has also made specific recommendations regarding the application of settlement language.  Download your copy here of MSP liability guidelines and case settlement protocols from Gould and Lamb.

Click Here to Download the MSP Compliance Protocols User Guide from Gould and Lamb
Download Gould and Lamb’s Medicare Secondary Payer Compliance and Protocols User Guide

Download the MSP Compliance Protocols user guide today!

Liability Guidelines and Case Settlement Protocols

Collateral Source Rule Does Not Relieve Plaintiffs of MSP Recoupment Obligation

On May 24, 2010 the Superior Court of New Jersey, Appellate Division, decided the case of Ilse Theresa Jackson v. Hudson Court, LLC.  At issue was a request by the plaintiff for a court ordered allocation of settlement funds in order to avoid payment of a Medicare lien.

After settlement of the underlying case, the plaintiff sought to obtain a court order designating that the settlement proceeds were for pain and suffering or for other amounts not related to medical services, notwithstanding the fact that conditional payments had been made by Medicare. Ms. Jackson’s contention was based upon state collateral source doctrine which forecloses recovery of expenses received (or to which she was entitled) in duplication of her recovery.

In short, she argued that no plaintiff should have to reimburse Medicare in a personal injury claim because Medicare’s lien would be satisfied from funds not recovered for medical expenses. Basically, she sought the court’s cooperation in categorizing her settlement proceeds to avoid Medicare lien repayment.

Collateral Source Statute

The court, interestingly, reviewed a prior ruling in which it was found that collateral source statute does not apply to reimbursable benefits paid by Medicaid by likening the reimbursement principles to Medicare liens. Stating that Medicare “has a nearly unqualified right to reimbursement” the court found that the collateral source rule allows a personal injury settlements to include recovery of medical expenses paid for by Medicare.

The court also took the opportunity to point to prior federal case law which established where state collateral source rules “frustrate” MSP reimbursement rights, they are pre empted.

For purposes of MSP compliance, it would appear that, at least in New Jersey, Medicare liens cannot be avoided by hiding behind the collateral source rule or by a creative allocation of settlement funds. The court there recognized not only the pre eminence of the MSP statute as compared to state law but also advised the tort industry that they would not be complicit in rulings that avoid Medicare’s recovery interests.

Accordingly, Gould and Lamb recommends conditional payment research early in the tort process in order to identify Medicare’s recoupment potential and the best strategy for maximizing third party recovery, limiting contingent liability and ensuring MSP compliance.

Click Here to Download the MSP Compliance Protocols User Guide from Gould and Lamb
Download Gould and Lamb’s Medicare Secondary Payer Compliance and Protocols User Guide

Download the MSP Compliance Protocols user guide today!