Transcript Document

STRYKER REJUVENATE
LIEN RESOLUTION UPDATE
Deeper Discussion of Medicare, Medicaid &
Private Lien Issues
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Agenda
• Introductions – Ginger Susman
• General Update – Pete Flowers & Ellen Relkin
• Medicare Lien Resolution Update – Bob Marcino
• Medicaid Lien Resolution Update – Bob Marcino
• Private Lien Resolution Update – Bob Marcino
• Closing and Q&A – Ginger Susman & Bob Marcino
Introductions
• Pete Flowers, Esq.
Meyers & Flowers
• Ellen Relkin, Esq.
Weitz & Luxenberg
• Ginger Susman, Esq.
• Bob Marcino, Esq.
President, Providio
General Counsel,
Providio
General Update
• Enrollment period opened 1/16/15
• Communications regarding lien process ongoing
• Town halls, email communications, this webinar
• Lien Situation is Fluid – Mass Tort Lien Resolution Processes
Differ in many ways from Single Event Lien Resolution
• Lien amounts &/or applicable program terms will not be definitively
known for all lien types prior to close of enrollment period but you will
have strong understanding of the framework where most important:
• Medicare model amounts
• Medicaid program terms
• Medicare Advantage terms
• Private lien terms (LRP)
Other gov’t lien terms
Private lien terms (non-LRP)
Lien Resolution in Stryker
MSA OBLIGATIONS & REQUIREMENTS
Medicare
Medicaid
Other
Government
Medicare
Advantage
Private
4 Different Lien Types To Be Resolved
Medicare: VOE* and Group Model Resolution Method
Medicaid: VOE* and Offset and Holdback agreements by State
“Other Government” Liens addressed individually
Medicare Part C: VOE and LRP (lien resolution programs)
Private Liens also being addressed in LRPs above, and in
some cases individually
* VOE means Verification of Entitlement to see who is covered
Medicare Group Resolution Model
• Group modeling is an alternative resolution approach for Medicare liens
available only in mass torts
• De facto method in large consolidated settlement programs
• Certain rules apply and are non-negotiable including no opt-outs, no review of individual
CPLs, and no appeals
• Why do the vast majority of mass tort settlement programs utilize group
resolution modeling of Medicare liens?
• Good lien reductions for overwhelming majority of claimants
• Provides certainty on program terms prior to enrollment
• Enables significantly faster clearance
• In Stryker, no need for Medicare Set Asides
• Fair, group-oriented approach
• Downside of modeling?
• There are always a small number of claimants who are disadvantaged by the model – bell
curve dynamics
Stryker Medicare
Part A and Part B
Global Values
CMS Approved Global
Value
$19,130
$8,776
$10,353
$2,359
Medicare Resolution Model
If/Then determination depending on date of
eligibility relative to revision date and other
health coverage
% of
$300,000
Award
Entitled to Medicare prior to revision and through 6
months after revision
6%
Entitled to Medicare after revision but within 6
months after revision
3%
Entitled to Medicare before revision but proof of
other primary payer within 6 months after revision
3%
Proof of other Primary Payer for a Group Health Plan
Prior to revision and through 6 months after revision
1%
Entitled to Medicare after revision but within 6 months
$1,076 after revision – and Proof of other Primary Payer for
a Group Health Plan
Proof of other Primary Payer for a Medicare Part C
$0 Plan Prior to revision and through 6 months after
revision
0.4%
0%
Medicare Group Model (notes)
• The $19,130 model obligation for revisions includes
additional compensation beyond base awards for:
• Controlled osteotomy
• Femur fracture requiring osteotomy with cabling
• Femur fracture during revision (or re-revision) requiring cabling but
no osteotomy
• Repair/reattachment of abductor muscles
• Dislocations
• Includes future care. No Medicare Set Asides required
Medicare Group Model – Example 1
Medicare paid the whole way
• Claimant was on Medicare prior to and after revision and
had no other health coverage
• Result: Claimants pays the full Medicare model amount of
$19,130
• Approximately 70% of Medicare entitled Stryker claimants
fall into Example 1
Medicare Group Model – Examples 2 & 3
Where Medicare paid for pre op and revision itself
• Example 2
• Claimant on Medicare prior to and for revision, BUT a group health plan
(“GHP”) asserts a lien for follow up care beginning 4 months after the revision.
• The GHP lien, after relatedness audit and negotiated reduction totals $3,250.
• Result: Claimant pays Medicare $10,353 plus the GHP lien of $3,250 for a total
of 13,603.
• Example 3
• Same as Example 2 except resulting GHP lien higher at $12,225 due to more
extensive and expensive follow up care.
• Result: Claimant pays Medicare the same $10,353 plus the GHP lien of
$12,225 for a total of $22,578.
•
• Approximately 5% of Medicare entitled Stryker claimants fall into
Examples 2 and 3
Medicare Group Model – Example 4 & 5
Where Medicare paid for follow up and future care
• Example 4
• Claimant was on Medicare but not until 4 months AFTER their
revision. GHP asserts a lien for the revision at $32,000. After audit
and negotiated reduction, the GHP lien comes down to $23,360.
• Result: Claimant pays the GHP lien of $23,360 plus Medicare model
lien amount of $8,776 for a total of $32,136.
• Example 5
• Same as Example 4 but GHP final lien is less at $9,100.
• Result: Claimant pays the GHP lien of $9,100 plus Medicare model
lien amount of $8,775 for a total of $17,875.
• Approximately 5% of Medicare entitled Stryker claimants fall into
Examples 4 and 5
Medicare Group Model – Example 6
Where Medicare Part C paid the whole way
• Claimant was on Medicare but had a Medicare Part C
plan (also known as Medicare Advantage) before and well
after their revision. The Medicare Part C plan asserts a
lien of $28,500. After audit and negotiated reduction, the
Part C lien is $17,100
• Result: Claimant pays the Part C lien of $17,100 and pays
Medicare nothing
• Approximately 30% of Medicare entitled claimants will have had a
Part C plan at some point before their revision or after. About ½ of
them fall into this example where Medicare Part C paid the whole
way.
Medicare Group Model – Lesser Amounts
Stryker Medicare
Part A and Part B
Global Values
CMS Approved Global
Value
$2,359
If/Then determination depending on date of
eligibility relative to revision date and other
health coverage
% of
$300,000
Award
Proof of other Primary Payer for a Group Health Plan
Prior to revision and through 6 months after revision
1%
Entitled to Medicare after revision but within 6 months
$1,076 after revision – and Proof of other Primary Payer for
a Group Health Plan
0.4%
Medicaid
• Lien obligation by injury varies by State – no model
• Average holdback range: 33% - 40% “offset” (i.e., reduction for
attorneys fees/costs)
• Most states have 20% holdback (max % of gross settlement)
• Some states have higher holdback – highest is 35% of gross
• Review the communication sent by leadership for details of recent
program terms on a state-by-state basis
• Medicaid agencies will not agree to terms until after VOE
commences
• This will occur when all enrolled claimants are identified upon close of
enrollment period.gross
Other Government Liens
gross
• Examples: Tricare, VA, FEHBA
• No program terms
• Providio will negotiate directly with other government lien holders
• You will be asked to provide Providio with relevant
correspondence
Medicare (Parts C)/Medicare “Advantage”
• The Medicare Advantage process of entitlement
verification (VOE) will be accomplished through a number
of lien resolution programs (LRPs)
• Rawlings LRP Confirmed
• Discussions in process with Gibson Sharps/Kim West group
• If claimant’s Medicare Advantage plan is not part of one of the
LRPs, then Providio to handle one-by-one, directly with the Part C
plan.
Rawlings LRP Terms
• LRP in place with Rawlings
• Rawlings estimates they will represent 25-30% of GHPs nationwide for Stryker
• Current list of committed Rawlings PLRP GHPs (in process of adding more):
• Aetna, Inc.
AmeriGroup
AvMed, Inc.
BCBS Association
BCBS South Carolina
BCBS Vermont
CIGNA HealthCare, Inc.
Coventry Health
Government Employees Health Assoc. (GEHA) Group Health Cooperative (including KPS
Health Plans)
Health Care Service Corporation, i.e. BCBS TX, IL, NM, OK HealthNow New York, Inc.
Johns Hopkins Healthcare
Priority Health
WellCare Health Plans (Medicaid Plan)
• Lien obligation based on actual claims paid:
• Automatic 40% “offset” (reduction for attorneys fees/costs) OR
• Maximum of 25% of gross settlement*
• Claimant pays whichever is less
• Anti-subrogation state laws apply
• State-based made whole laws do not apply
Private Health Insurance
gross
• The LRPs for Medicare Advantage will be used to resolve private
liens too
• Same terms will apply
• Claimants automatically enrolled in whichever LRP program that
applies unless they opt-out by the “opt-out deadline”
• A claimant letter regarding the lien resolution process and associated fees will
be coming soon and the letter will contain an opt-out form for any claimant
desiring to have their private liens handled individually
• Opt out deadline to be announced
• If a firm has already elected to use Providio for private lien resolution through
the LRPs that election does not obligate individual claimants, they can still optout.
• For private liens with any GHPs not part of the LRPs there will be no
program terms
• Providio will negotiate directly on an individual basis with such GHPs
Frequently Asked Lien Questions
• What if I already received a CPL from Medicare for a client and it’s
less than the model amounts? Is there an appeal or opt-out process?
• If my client has a re-revision for which s/he obtains a future award,
does this round of lien resolution cover everything or will s/he owe
more for liens with the second compensation award?
• How will lien resolution be handled for claimants who are medically
unable to be revised?
• Will I know my clients’ lien amounts prior to enrollment?
• What if Broadspire paid for the revision or I have proof that my client
paid out of pocket?
Frequently Asked Lien Questions
• What is the timeframe for overall lien resolution and how should I set
client expectations?
• How are ERISA plans handled?
• What if my client’s Medicare Advantage or other private health plan is
not covered by an LRP?
• Do I still need to consider Medicare Set Asides for any of my clients or
does the Medicare model process take care of that?
• What information should I send to Providio to make sure they are
working my clients’ liens?
Cost of Providio Lien Services*
*
Medicare (Parts A & B)/Medicaid
Lien Resolution -- Current Revisions/Care and
Future Revisions
1 lien - $350/claimant
2 liens - $600/claimant
Rawlings LRP Lien Resolution (including
Medicare Advantage (Part C)) – Current
Revisions/Care and Future Revisions
$212/claimant**
Other LRP Lien Resolution (including
Medicare Advantage (Part C)) – Current
Revisions/Care and Future Revisions
TBD
Non-PLRP Private Lien Resolution – Current
Revisions/Care and Future Revisions
1 lien - $850/claimant
Additional liens - $250/lien
Other Governmental Liens – Current
Revisions/Care and Future Revisions
1 lien - $850/claimant
Additional liens - $250/lien
All VOE fees are being paid out of the MDL and NJ common benefit so they’re not listed here as direct claimant cost.
**
Providio’s Rawlings LRP total lien resolution fee is $425/claimant. Rawlings has agreed to reimburse 50% of
this in recognition of the value the PLRP program brings to the overall process, and to help defray the
lien resolution cost to plaintiffs.
Closing and Q&A
• Communication protocol for maximum lien reductions in most efficient
manner
• For urgent questions, please email us at [email protected]
• If you missed the deadline to select Providio for your private lien
resolution but would like to utilize our services, please email your
request to us at [email protected]
• Providio is also the QSF administrator for Stryker. Information
relevant to distribution coming later (early summer)
• For urgent questions, please email us at [email protected]
• Q&A