Expert Insight into the Latest News & Updates for Medicare Secondary Payer Compliance

Ask Annie: The Amended Review Process in Detail

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.”

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Yet Another Price Drop for Oxycodone/APAP Tablets

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.

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Updates from CMS Regarding NGHP Processes

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.

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