3-29-2011; Will changes to the Medicare Secondary Payer Statute assist in resolving Medicare issues and finally give us a way to appeal what are sometimes incomprehensible MSA values?

On March 14, 2011, the Strengthening Medicare and Repaying Taxpayers Act of 2011 (SMART Act) (H.R. 1063) was introduced in the U.S. House of Representatives. The SMART Act proposes major amendments to the Medicare Secondary Payer Statute (MSP). Track progress here: http://www.govtrack.us/congress/bill.xpd?bill=h112-1063       

The SMART Act’s reform proposals target multiple areas of MSP compliance including:

•       Obtaining CMS’ reimbursable conditional payment amount—this will help the parties confirm amounts which will be owed for past medical. Under CMS’ current process, the parties generally cannot obtain the exact reimbursable conditional payment amount until after the claim settles.

•       Requiring CMS to respond  to requests  for conditional payment information within set timelines—finally you won’t be stuck in the purgatory of never knowing when you will receive information you need to resolve past payments, hopefully within 120 days or less;

•       MSP appeal rights—when you receive the $100k MSA ruling for a person who hasn’t had a surgical procedure, you may have somewhere to turn as review through an administrative law judge and administrative review board, and access to judicial review in the district court of the United States is proposed in a manner which would be similar to the appeals procedure under regulations for hearing procedures respecting notices of determinations of nonconformance of group health plans.

•       MSP threshold exemptions—the SMART Act would require that CMS establish an annual MSP threshold exemption amount below which MSP compliance would not be necessary. The SMART Act’s proposal of a yearly MSP threshold exemption amount replaces the flat $5,000 monetary threshold exemption proposed last year.

•       MSP statute of limitations—you would no longer have to worry about someone looking into a claim well after all parties have retired as the SMART Act would establish a Three (3) year Statute of Limitation for MSP Claims.

We will keep you advised of changes as they occur and as previously noted, Shawn R. Biery has completed course work and testing from two sources to obtain his Medicare Set-aside Consultant Certified (MSCC) credential.

Please feel free to contact Shawn R. Biery, J.D., M.S.S.C. at sbiery@keefe-law.com with any questions regarding Medicare Set-Aside issues.

3-29-2011; The Greater Oak Brook Chamber of Commerce Presents HFN’s Annual Healthcare Showcase If Health Insurance is Just Pre-paying expenses…How Do I Manage Healthcare Risk Today?

HFN is hosting this event and inviting all of our readers to this interesting and challenging presentation.

Topics & Speakers will include:

·         Employer Expectations are High for Good Reason!

o    Mary Lynn Fayoumi, CAE, SPHR, GPHR, President/CEO The Management Association of Illinois

·         Healthcare Reform and the Rapidly Evolving Self Insurance Market

o    Walter Roland, Senior Vice President, D.W. Van Dyke & Co., Inc.

·         Do You Know What You Must Do Now With Your Health Plan? A Checklist to Live By!

o    Ronald Walter, CLU, ChFC, President Professional Benefit Administrators, Inc.

·         Why is the Employer’s Opportunity so Significant Today?

o    David Kolb, FACHE, President/CEO HFN, Inc.

Date: Wednesday, May 4, 2011

Time: 7:15 – 8:15 Health Assessments*

7:30 – 8:15 Full Breakfast

8:15 – 10:00 Presentation & Discussion

Location: The Grotto Oak Brook, 3011 Butterfield Rd, Oak Brook, IL 60523 (630) 571-5700

RSVP: Please RSVP By April 27, 2011 to Danielle Kolego 630/990-8501 or email kolegod@hfninc.com

3-14-2011; Breathless in Naperville--whew, firefighter denied lifetime line-of-duty disability pension for cigarette smoking

 In the “you-can’t-make-this-stuff-up” category, we reviewed a recent ruling by the Second District Appellate Court in which they considered a claim by a firefighter seeking lifetime line-of-duty disability pension benefits. Many observers were concerned when Illinois hyper-aggressive firefighter unions were able to get the controversial “firefighter’s presumption” for things like pulmonary conditions in Illinois workers’ compensation, the same presumption might start to be followed in disability pension claims. This decision appears to indicate that may not be happening.

In Lindemulder v. The Board of Trustees of the Naperville Firefighters' Pension Fund, (No. 2-10-0063 March 8, 2011), the Appellate Court found the Circuit Court properly affirmed the Pension Board's decision denying Plaintiff firefighter's application for line-of-duty pension and occupational disease pension.

The facts indicate Plaintiff Lindemulder, age 50 was exposed to second-hand smoke during his childhood and thereafter. There is no dispute he began smoking cigarettes regularly at age 16 or 17. During his employment with Naperville as a firefighter, he smoked one to one and one-half packs per day for years and eventually suffered from chronic obstructive pulmonary disease or COPD.

A physician certified Plaintiff had COPD from years of smoking which rendered him unable to tolerate physical demands of his job as a firefighter. Plaintiff failed to prove he was exposed to occupational diesel fumes or that such fumes caused or aggravated COPD. Various physicians testified a lifetime of cigarette smoking was the likely cause of his COPD.

The Circuit and Appellate Court agreed the Illinois Pension Code required the firefighter who may have been subject to heavy smoke fumes on the job must prove that disability resulted from service as firefighter and not from the personal decision to smoke cigarettes.

Please do not hesitate to reply with your thoughts and comments.