CMS seeks to impose civil money penalties in a variety of situations, and affords a number of safe harbors and get out of jail free cards for responsible reporting entities. Interestingly, the proposal aims to use the conditional payment dispute and appeals process as a launching pad for possible civil money penalties.

A “counter-higher” refers to a specific type of determination issued by Medicare with respect to a submitted Workers’ Compensation Medicare Set-Aside Allocation (WCMSA). The question posed presumes the parties are settling for an amount that exceeds one of Medicare’s workload review thresholds: $25,000 for a case involving a Medicare beneficiary or $250,000 for a case involving a claimant with a “reasonable expectation of Medicare enrollment within 30 months of the date of settlement.”

The U.S. Department of Justice (“DOJ”) is ringing in the New Year with the Medicare Secondary Payer Act (“MSPA”). On January 8, 2020, the U.S. Attorney’s Office for the State of Pennsylvania announced a $6,604.59 conditional payment settlement with Philadelphia firm Simon & Simon.

We previously shared a price update in August of regarding a widely used opioid-acetaminophen (oxycodone/APAP) combination product. Another price drop has been announced, and this time it is for all oxycodone/APAP tablet strengths, 5-325mg, 7.5-325mg and 10-325mg.

CMS has posted two updates this week:

The Total Payment Obligation to the Claimant (TPOC) threshold for reporting Section 111 claims and for Conditional Payment recovery efforts will remain at $750 for the 2020 calendar year. The Alert is available here.
CMS will be hosting a town hall meeting on January 14, 2020 at 1pm EST to discuss common Commercial Repayment Center (CRC) Ongoing Responsibility for Medicals (ORM) recovery topics.

A “zero allocation” is what we call not setting money aside to pay for a claimant’s post-settlement Medicare-covered medical needs. A zero allocation is possible in two situations.

On November 18, 2019, CMS released an alert titled, “Important Reminder for Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) Regarding Medicare Beneficiary Identifier (MBI)

That can?  It’s still getting kicked.  Earlier this week the White House Office of Management and Budget updated the timeline on the release of regulations

As you may recall, we have been down this road before with a different Baltimore law firm and a Pennsylvania practitioner. Standard operating procedure when settling a personal