SYNERGY SETTLEMENT CONSULTING, LLC
ORLANDO, FLORIDA

Medicare Secondary Payer Compliance as it relates to Medicare “futures” has become such a concern for all parties that settlements are frequently delayed over these issues. Having a thorough understanding about the obligations of all parties when it comes to this issue is of paramount importance. First and foremost, the issue only arises when a settlement involves a Medicare beneficiary or someone with a “reasonable expectation” of becoming a Medicare beneficiary within 30 months. The information contained herein will provide an overview of the issues counsel should be concerned about when it comes to Medicare Secondary Payer Compliance. If a client is a Medicare beneficiary or has a “reasonable expectation” of becoming one in 30 months, then we can help. We focus on the intricacies of the MSP so you don’t have to. Rely on us to assist with navigating the difficult MSP related issues. To learn more about select MSA related topics, please see the highlighted subjects below. If an injury victim is covered by Medicare, you have to worry about the Medicare Secondary Payer (MSP) statute. The MSP is a series of statutory provisions enacted during the 1980s as part of the Omnibus Reconciliation Act with the goal of reducing federal health care costs. The MSP provides that if a primary payer exists, Medicare only pays for medical treatment relating to an injury to the extent that the primary payer does not pay. CFR Title 42, Part 411, Subpart B, Section 411.20 (2) provides “Section 1862(b)(2)(A)(ii) of the Act precludes Medicare payments for services to the extent that payment has been made or can reasonably be expected to be made promptly under any of the following” (i) Workers’ compensation; (ii) Liability insurance; (iii) No-fault insurance. There are two issues that the MSP deals with: (1) Medicare payments made prior to the date of settlement (“conditional payments”) and (2) future Medicare payments for covered services. Recently, there have been some developments that indicate that the MSP may be enforced to a greater extent in liability settlements for future Medicare covered expenses. There are two CMS memorandums that have been issued in relation to set asides for liability settlements. The first one was issued by the Dallas Regional Office and summarizes the obligations of the parties to protect Medicare’s “interests” in liability settlements. The second was issued by the Baltimore HQ office and provides a method of avoiding the need for a liability Medicare set aside when the treating physician certifies there will be no need for future medical care. be used for Medicare covered expenses for injury related care. Once the set aside account is exhausted, an injury victim gets full Medicare coverage without Medicare ever looking to the remaining settlement dollars to provide for any Medicare covered health care. Medicare may approve the amount to be set aside in writing and agree to be responsible for all future expenses once the set aside funds are depleted if the parties choose to submit the allocation to CMS for review. Limitations on Hospital/Provider Liens When the Plaintiff is on Medicare "I learned of Synergy through the state trial lawyers association when I was looking for help in dealing with Medicare. As you know, dealing with Medicare can be difficult and time consuming. We all get the articles and updates regarding Medicare, but Synergy does an incredible job of clarifying so many questions. I cannot thank you and the Synergy staff enough for the assistance, insight, and professionalism. You can be sure that I will only be recommending Synergy to my clients for Medicare issues in the years to come." Many injury victims find it very difficult to manage a lump sum settlement on their own. Implementing a sound financial plan with the right combination of investments can prevent this from happening. However, most financial products have costs associated with them and even though a physical injury recovery is tax-free, once invested the gains are taxable in nearly any product except for structured settlements. Nevertheless, there are many good options for managing your physical injury recovery and we can assist you developing a plan that is right for you. Certain financial products have less risk and can offer guarantees of principal to limit downside risk since you only get one opportunity to preserve your recovery. Our job is to give you sound advice about the options to let you make the best possible decision. You may want to consider mutual funds, managed accounts, annuities, life insurance, college plans and long term care insurance. All of these products can be wrapped up inside trusts to protect you and your loved ones. It is important to explore the many options available and that is where we come in. Structured settlement annuities are exceptionally flexible and can be designed to meet virtually any set of needs. A relatively simple payment schedule can be set up that provides for equal payments at set intervals – for example, every month for 20 years. Yet payments need not be in equal amounts. Someone who will need a new wheelchair every three years might elect to receive a larger payment every 36 months to help defray the cost. (This would presumably be in addition to the regular payments.) In any physical injury case, the plaintiff and defendant negotiate issues such as the victim’s medical care and basic living and family needs. Oftentimes, one side (or both) will bring in an expert, such as a structured settlement planner, who provides calculations on the long-term cost of these needs. When there is agreement on the amount of damages due the injury victim (which can happen before, during or after a lawsuit), the victim can select a periodic payment plan that meets his or her needs and the defendant will agree to make the future payments via a structured settlement. The defendant then assigns this obligation to an experienced third party, a life insurance company that funds the damage payments with an annuity.