Great questions! Some answers:

Back on Feb. 4, 2019, the North Carolina Department of Health and Human Services announced the selection of Prepaid Health Plans that will participate in Medicaid managed care when the program launches in November 2019. The Department awarded contracts to five entities:

• Statewide PHP contracts were awarded to the following entities which will offer Standard Plans in all regions in North Carolina:
  • AmeriHealth Caritas North Carolina, Inc.
  • Blue Cross and Blue Shield of North Carolina
  • UnitedHealthcare of North Carolina, Inc.
  • WellCare of North Carolina, Inc.
  • A regional PHP contract was awarded to Carolina Complete Health, a provider-led entity, which will offer plans in Regions 3 and 5.

Plaintiff lawyers who represent clients who are Medicaid recipients who have been in car wrecks need to track what these entities pay for medical treatment in order to account for the Medicaid lien and repay the government.

Before this privatization of Medicaid, all of the subrogation has been handled by a group called HMS. Now that the PHPs have come along, we have to request subrogation information from each PHP.

Here is a list of the subrogation contacts for the Medicaid PHPs.

PHP Medicaid Lien Contact Information

Carolina Complete Health

Rawlings Group
4 Eden Parkway
La Grange, KY 40031
Phone: 888-285-1276
Fax: MANUAL FILE COORDINATOR at 502-440-1100
Email: CenteneReferrals@rawlingscompany.com

WellCare

Rawlings Group
4 Eden Parkway
La Grange, KY 40031
Phone: 888-285-1276
Fax: MANUAL FILE COORDINATOR at 502-440-1100
Email: CenteneReferrals@rawlingscompany.com

Healthy Blue

 P.O. Box 659940
San Antonio, TX 78265-9939
Phone: 844-916-3651
Fax: 844-634-2520
Email: NCCompliance@healthybluenc.com

AmeriHealth

Attn: Subrogation Unit
200 Stevens Drive
Philadelphia, PA 19113
Phone:215-863-5837
Fax: 215-863-5221
Email: subrogation@amerihealthcaritas.com

United Healthcare

Optum Subrogation
11000 Optum Circle
Eden Prairie, MN 55344
Fax: 800-842-8810
Email: subrogationreferrals@optum.com

Trillium: www.trilliumnc.org 

Phone: 877-695-1296
Email: Trillium@gainwelltechnologies.com

_________

The subrogation providers above are subject to change, but this is the list as of 8/25/2022.

Chris Nichols
Nichols Law Firm
North Carolina and Raleigh Personal Injury Lawyer

The Governor signed the new bill incorporating the holding of Wos on July 18, 2013. The bill is effective immediately. You can view House Bill 982, in final mark-up version here: House Bill 982 

Here are the things we KEPT in the old § 108A-57. Subrogation rights; withholding of information a misdemeanor:

• Medicaid is still limited to a maximum of 100% of the lien OR One Third (1/3) of the gross settlement.
• Medicaid still prorates within their 1/3 with unpaid medical providers asserting liens.
• Payment by the lawyer of the 100% or 1/3 of the gross settlement is full and final payment of Medicaid’s lien (but medical lien holders paid pro-rata still get are owed their balances pursuant to NCGS 44-49 and 50. 

Here are the NEW provisions that reflect the Supreme Court’s determination that our previous Medicaid statute was in conflict with Federal law:

• Medicaid recipients can challenge the 1/3 or 100% lien by filing a Petition with a court of competant jurisdiction for “a determination of the portion of the beneficiary’s gross recovery that represents compensation for the Medicaid claim.”
• TIMING OF PETITION: Those petitions must be filed within 30 days of all parties signing a settlement agreement OR court approval of the settlement OR a judgment being issued.
• The Court will conduct an evidentiary hearing and may consider any factors it deems just and reasonable in determining the allocation of the settlement.
• The burden of proof is on the petitioner to prove by “clear and convincing evidence” that Medicaid is demanding too large a portion of the settlement.

One other excellent part of the new statute says Medicaid can compromise the liens at any time:

(a3) Notwithstanding the presumption arising pursuant to subsection (a1) of this section, the medical assistance beneficiary and the Department may reach an agreement on the portion of the recovery that represents compensation for the Medicaid claim. 

In the past, Medicaid took the position they could not negotiate their lien with recipients. This new portion allows for that negotiation to occur at any time, even before a petition is filed.

Chris Nichols
www.NicholsTrialLaw.com

The oral argument can be heard here: http://coop.ca4.uscourts.gov/OAarchive/mp3/10-1865-20111026.mp3#

Chris Nichols
www.NicholsTrialLaw.com

I was sent this brief “idiot’s guide” to dealing with Medicare and thought it was an excellent summary of the process. I’ve posted it in full, along with the contact information for a company that will help with the lien resolution process. I am not endorsing their product as I have never used their services.

http://lienblog.wordpress.com/2010/07/02/the-idiot%E2%80%99s-guide-to-medicare-lien-resolution/

The Idiot’s Guide to Medicare Lien Resolution

Typically, Medicare liens are placed on the personal injury case of a person whose treatment is paid by Medicare. Medicare’s agents, the COBC, MSPRC, and CMS have a right to recover funds which would not have been paid without the negligent act which harmed the plaintiff-beneficiary.

If you are the Medicare beneficiary and plaintiff in a lawsuit, your attorney should handle the Medicare liens for you. If you are the attorney, but you don’t know how to handle the lien, or just need some help, follow these simple steps:

1. Report the case to the COBC
   1. Call (800) 999-1118
   2. Be prepared to give the following Plaintiff/Beneficiary information:
      1. Name
      2. Social Security Number
      3. Medicare Number (a/k/a HIC Number)
      4. Date of Birth
      5. Address
      6. Date of Incident
      7. Injury (the COBC prefers physical body parts )
      8. Defense insurance (if known)
2. This should be the only time you deal with the COBC
3. Wait 10-15 days. During this time period the COBC will transfer the file to the MSPRC, another Medicare agency. At the end of this time period you should receive two (2) pieces of Medicare lien information from the MSPRC:
   1. First, you will receive a Beneficiary Information Questionnaire (you will recognize this document based on the red grid lines on the back pages). This document can be ignored if, and only if, the plaintiff-beneficiary’s information has not changed.
   2. Concurrently, you will receive a Rights and Responsibilities Letter. This will give some information on the Conditional Payment Letter process. No action on your part is required.
      1. This Rights and Responsibilities Letter starts a countdown until you should receive a Conditional Payment Letter (a/k/a the initial lien). That countdown will last 65 days – however, you need something else to receive the letter.
      2. Within the 65 day period, you need to send consent and proof of representation to the MSPRC. If you do not send the consent, you will not receive information on the Medicare lien, nor will you be able to speak to MSPRC representatives regarding your case.
         1. Unfortunately, the MSPRC is notoriously slow. Without constant checks on the status and timeline, your Conditional Payment Letter probably won’t arrive within the 65 day period.
            1. Be sure to call the MSPRC to check the status of your consent (its validity).
            2. Be sure to call the MSPRC multiple times after to check the status of your Conditional Payment Letter.
            3. Please be ready to wait when you call theMSPRC. Hold times range anywhere from 10 to 55 minutes (and increasing). In fact, due to theMSPRC’s inability to handle current volumes of mail, its call center is now closed on Fridays.
4. After all that time and effort you should receive the Conditional Payment Letter.
   1. But if you did not bother to call the MSPRC – you probably don’t have it!
   2. You’ve received the Conditional Payment Letter, now what?
      1. Review the payments. Check every ICD-9 code and injury to make certain they relate to the plaintiff’s sued-for injuries.
         1. Hint: ICD-9 Code 250.00 (Diabetes Mellitus) usually does not relate to malpractice or a personal injury.
5. On nearly every Conditional Payment Letter there will be unrelated codes – this means the lien is too high and Medicare is claiming funds to which it is not entitled.
6. If you have time before settlement you should Dispute theConditional Payment Letter.
   1. The MSPRC requires these in writing.
   2. Dispute the codes that are unrelated and explain why the MSPRCwas wrong to include them.
   3. Be detailed.
   4. The MSPRC will take 60-90 days to review your dispute. When it replies to your dispute it will not give reasons, it simply sends a new Conditional Payment Letter.
   5. The case is settled, how do I pay Medicare?
      1. First you have to request a Final Lien Demand by notifying theMSPRC of settlement.
         1. Be sure to include the settlement, attorneys fee, any costs incurred (plus an itemization), and the date of settlement.
         2. In 30-45 days you will receive a Final Lien Demand. This is the amount you must pay to Medicare from the settlement proceeds.
            1. You have 60 days to repay the lien before interest accrues.
            2. If you fail to pay within 60 days the interest will accrue for all 60 days plus any additional time.
7. A Final Lien Demand is not really final:
   1. You can appeal the Final Lien Demand on the basis that unrelated payments are included in the lien.
      1. You must do so within 120 days.
      2. Be very careful and detailed when appealing. Keep in mind the MSPRC is the judge, jury, and executioner at this point of the Medicare lien appeal.
   2. Other methods exist to lower the lien, including:
      1. Compromises with CMS.
      2. Waivers through the Social Security Administration.
      3. Now that I appealed, how does my client get aMedicare Lien Reimbursement?
         1. Medicare lien reimbursements (for “overpayment”) take 10-14 weeks to be processed and sent to your client.
         2. You don’t have to do anything once the appeal has been agreed to by the MSPRC.
            1. But the check will go straight to the last-known address for the beneficiary.
            2. If you want the check to go to your office you must contact the MSPRC and request it be sent to you.
               1. Usually this check arrives as a two-party check.
               2. This will protect the interests of all heirs who have an entitlement to the lawsuit funds.
               3. Now you can put the check into your escrow account and disburse the funds as is legal, ethical, and agreed to by the plaintiff, heirs, and secondary lienholders.
8. Timelines:
   1. Reporting to COBC – Day 1
   2. COBC transfer to MSPRC – Day 3-5
   3. MSPRC sends Rights and Responsibilities letter, starting 65 day countdown to a Conditional Payment Summary, or Initial Medicare Lien – Day 15-20
   4. Conditional Payment Letter arrives – Day 80-85
   5. Disputes add 60-90 days
   6. Compromises add 60-90 days
   7. Appeals add 60-90 days
   8. Notice of settlement to receive Final Lien Demand
      1. Was 10-21 days
      2. Now is 30-45 days
      3. If you do everything right in Medicare Lien Resolution, you could resolve a lien within 110 days; but, if you let letters sit and do not take the time to carefully review and resolve your liens, they could take years.
         1. Report early;
         2. Call often; or,
         3. GET HELP! Lien Resolution Servicesspecializes in this process. When we see a Medicare letter, we know what to do with it – reducing lag time and speeding up the lien resolution process. LRS makeslien resolution 100% of our focus; we take this administrative work off your hands providing you with time to practice law and litigate cases.
         4. Best of all – The cost of lien resolution isbillable to the client, just like an expert fee. The attorney pays nothing; and, while the client pays a small fee, he or she ultimately benefits by a reduced lien, faster disbursement, and results.
         5. Contact us for all of the above.

Ryan J. WeinerCo-Founder Lien Resolution Services

www.lienresolutionusa.com
http://lienblog.wordpress.com
rweiner@lienresolutionusa.com

QUESTION: Is Medicaid’s lien capped at one third of liability proceeds received or half of what is left over after attorney’s fees? In other words, if I am pro-rating a Medicaid lien with 44-49 liens and my fee is 25%, are they still sharing a third or are they sharing 37.5%?

ANSWER: Medicaid gets no more than 1/3 of the total settlement. Your attorney fees are irrelevant to Medicaid’s share. The most Medicaid can get is 1/3 of the settlement, even if you charge only 1 dollar as a fee.
 
Medicaid will prorate with NCGS 44-49/50 liens within their 1/3 share. But remember that paying the parorata share of the 44-49/50 liens does not extinguish the balance of the medical bill. The client still owes the balance after the prorata share unless you negotiate a “final payment” compromise with the mediacl provider. 44-49/50 simply act as as a way to get the lawyer out of the middle and get the provider some money before they have to turn to a collection action to get it.
 
The 1/3 (or Medicaid’s portion thereof) DOES take care of Medicaid, in full.

_________________________

Chris Nichols
www.NicholsTrialLAw.com

Rebalancing the scales of justice

Barack Obama must stop the supreme court from providing immunity to health insurers and other corporate law-breakers

• by Simon Lazarus and Ian Millhiser
• guardian.co.uk, Thursday November 13 2008 18.00 GMT

Fourteen years ago, a single mother named Ann Dunham began a long, ultimately unsuccessful battle with cancer – and a simultaneous war with her health insurance provider. Over and over, as Ms Dunham’s son, Barack Obama, recounted during the October 6 presidential debate, company representatives suggested that his mother’s cancer “may have been a pre-existing condition and they don’t have to pay her treatment”.

Ann Dunham’s story is hardly unique. Millions of Americans know well that the pain of serious illness is often compounded by endless jousts with insurers arbitrarily withholding coverage of physician-prescribed care. Myriad court records tell the stories of people like Maureen Kurtek, who lost five fingertips and most of her right foot after her husband’s employer switched to an insurer which resisted continuing to cover her lupus treatment. And of construction manager James Lind, who was able to continue working despite his multiple sclerosis, until his insurer abruptly declined to continue paying for the prescription that had kept his MS at bay. And Rhonda Bast, who died after her insurer refused coverage of a bone marrow transplant which could have prevented her cancer from spreading to her brain.

Many of these sad stories could and should have been avoided. The fault lies with senior federal officials driven by the same deregulatory fervour responsible for enabling the imprudent lending frenzy behind the current financial crisis. In this case, however, the zealots do not run administrative agencies or departments. They preside at the United States supreme court. Over the past quarter-century, court majorities, led principally by Justice Antonin Scalia, have systematically dismantled the framework of laws designed to prevent benefit providers from breaking their promises to patients like Ann Dunham.

The keystone of this protective framework is the Employee Retirement Income Security Act, known by its acronym, Erisa. Congress passed Erisa in 1974 to protect the pensions and employer-provided health plans which millions of Americans rely upon. Yet the supreme court has twisted this law into something quite different. As noted by Senate judiciary chairman, Patrick Leahy, the court’s perversion of Erisa is a prime example of decisions that have turned laws “on their heads, making them protections for big business rather than ordinary citizens.”

Erisa sets strict standards to ensure that employers and insurers administering group benefit plans act “solely in the interests of beneficiaries for the exclusive purpose of providing benefits,” not their own bottom-line. But the court has rendered these protections meaningless. In a Catch-22 decision written by Justice Scalia, a 5-4 majority held that, when plan administrators violate their obligations under the law, victims may not recover any monetary compensation for resulting losses they suffer. Adding insult to injury, the court has read Erisa as a warrant for “pre-empting” – ie abolishing – pre-existing state law protections, leaving victims with literally no recourse. Thus, in the words of, the late Justice Byron White, the supreme court has achieved the “perverse anomaly of leaving those Congress set out to protect with less protection than they enjoyed before Erisa was enacted.”

When forced to apply the supreme court’s “tangled” Erisa rules, ordinarily circumspect federal judges have often harshly attacked them. Most famously, the late Chief Judge Edward Becker, a Republican named to the third circuit court of appeals by President Reagan, excoriated Justice Scalia and his allies for converting Erisa “into a shield that insulates HMOs from liability for even the most egregious acts of dereliction committed against plan beneficiaries, a state of affairs directly contrary to the intent of Congress.” Judge Becker stressed that the court’s distortion of Erisa creates “strong incentives for HMOs to deny claims in bad faith or otherwise ‘stiff’ participants.” The systemic result, he added, is a “‘race to the bottom’ in which the most profitable HMOs will be those that deny claims most frequently.”

A recently discovered insurance company memo (pdf) confirms Judge Becker’s insight. This smoking gun, an internal company directive, instructed claims processors to structure “new and existing policies” so as to ensure that they would be subject to Erisa. Once covered by this federal law originally hailed as a landmark safeguard for beneficiaries, the memo forecast, the company could eliminate over 90% of its payouts to claimants seeking redress for denials of coverage.

Immunity for health insurers is just one gift which the supreme court has given to powerful interests that find compliance with the law inconvenient. The most notorious recent example is the 2007 Ledbetter decision, in which the court’s five conservatives held that victims of pay discrimination have only six short months to seek relief – even if they do not learn of the discrimination until years later. But the supreme court has also thwarted Congress’ efforts to protect Americans with disabilities against discrimination (pdf). It has erected unprecedented barriers to patients seeking redress for unlawfully withheld Medicaid benefits, pre-empted state predatory lending (pdf) curbs, and extended lawsuit immunity to the manufacturers of dangerous medical devices. In case after case, the court has achieved de facto repeal of federal guarantees by eliminating citizens’ ability to enforce them in court, and, through pre-emption, secured outright repeal of state law protections.

As the new president rolls out new proposals for ensuring health and economic security, he should not ignore the court’s drive to roll back existing safeguards. If he acts fast, he could score some significant early wins, and send a clear signal that the new sheriff in town is serious about justice for ordinary citizens. Early in this Congressional term, it could be possible to legislatively “fix” decisions that distort major laws like Erisa and the Civil Rights Act equal pay guarantees upended in the Ledbetter case. His agency heads can rescind the mass of Bush administration regulations and policies that pre-empt vital state legal protections. His justice department can press the federal courts to faithfully construe laws in line with their original reformist purposes, and stop importing stealth deregulatory designs recently in vogue. Most important for the long-term, the president, together with allies in the Senate, can sensitise new judicial nominees to the priority of robust enforcement of guarantees protecting Americans’ pocket book needs.

By targeting courts that coddle corporate law-breakers, President Obama can engineer change that will save millions of Americans from major financial, physical, and emotional travail.

Simon Lazarus and Ian Millhiser are attorneys with the National Senior Citizens Law Centre

So when you make a settlement which will not cover “all” the bills, how do you handle this scenario? I see two ways to go about making the disbursement. I can’t say if one or the other is “right” as I don’t think the statutes clearly cover this.

It should go like this, hypothetically:

Scenario 1

Assume:

Med pay $2,000 (already paid to Chiro 1)

Settlement $10,000
Medicaid Lien: $5,000
Chiro 1: $1,000 (balance after med pay received of $2,000)
Chiro 2: $2,000 balance

So, now let’s apply the law and do the math:

$10,000 Settlement
-$3,333.33 Atty Fees
$6,666.66 Balance

1/3 of settlement is $3,333.33 for Medicaid purposes (Medicaid is limited to recovering 1/3 of settlement)

1/2 of Net is $3,333.33 for NCGS 44-49 lien purposes (Medical liens can only force the attorney to pay 1/2 of the Net settlement after attorney fees and it makes it easier when 1/2 of net and 1/3 are the same thing).

Medicaid shares pro-rata with unpaid medical providers within the 1/3.

$5,000 Medicaid
$1,000 Chiro 1
$2,000 chiro 2
$8,000 $3,333,3/$8,000 = 41.66% shares of the 1/3

Now we figure the prorata share for each lien holder using the percentage from above:

5,000 x 41.66% =$2,083.31
1,000 x 41.66% = $416.6
2,000 x 41.66% = 833.20

That’s how the 1/3 should be distributed BUT, since Medicaid is entitled to 100% of the medpay, they will get another $2,000 on top of the share above.

So:
$10,000 Settlement
-$3,333.33 Atty Fees
$6,666.66 Balance

-$2,083.31 Medicaid
-$416.6 Chiro 1
-833.20 Chiro 2
$3,333.50

-$2,000Medicaid Med pay
1,333.50 to Client

But there appears to be another way to do this. In the first scenario above we prorated Medicaid’s full lien, then paid Medicaid the $2,000 from the remainder of the settlement.

The second method would pay Medicaid the $2k medpay FIRST, then use the balance of the lien for proration purposes. That would give the other providers more money under pro-ration.

The second method would look like this:

Scenario 2

$10,000 Settlement
-$3,333.33 Atty Fees
$6,666.66 Balance

1/3 of settlement is $3,333.33 for Medicaid purposes

1/2 of Net is $3,333.33 for 44-49 lien purposes (makes it easier when 1/2 of net and 1/3 are the same thing)

Medicaid shares pro-rata with unpaid medical providers within the 1/3. (We’ve already taken out the $2k Medicaid will receive)

$3,000 Medicaid lien
$1,000 Chiro 1
$2,000 chiro 2
$6,000 $3,333.33/$6,000 = 55.55% shares of the 1/3

Now we figure the prorata share for each lien holder using the percentage from above:

3,000 x 55.55% = $1,666.50
1,000 x 55.55% = $555.55
2,000 x 55.55% = $1111.11

Since Medicaid is entitled to 100% of the medpay, they will get another $2,000 on top of the share above.

So:
$10,000 Settlement
-$3,333.33 Atty Fees
$6,666.66 Balance

-$1,666.50 Medicaid
-$555.55 Chiro 1
-$1111.11 Chiro 2
$3,333.50

-$2,000 Medicaid (Med pay)
1,333.50 to Client

Let’s compare scenarios now:

Scenario 1:

$2,083.31 (Medicaid prorated share) + $2,000 for med pay = 4,083.31 to Medicaid
$ 416.6 Chiro 1
$ 833.20 Chiro 2

Scenario 2:

$1,666.50 (Medicaid prorated share) + $2,000 for med pay = 3,666.50 to Medicaid
-$555.55 Chiro 1
-$1111.11 Chiro 2

So, technically, Scenario 2 is better for your clientin my mind because Medicaid is paid in full with $3,666.50 and there is more money available for the doctors (who are not paid in full but might be more likely to accept the higher % payment as payment in full).

I don’t know if there is a right or wrong to his one. I’m sure Medicaid would prefer to be paid more, and they may have a point since technically, the Medpay should have gone to them in the first place.

–Chris Nichols
www.NicholsTrialLaw.com

The article says that the Bush administration “will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals.”  The new rules go into effect in October, 2008

Charges can not be passed down to patients. The administrative rule stems from a 2006 law but the implementation was delayed for fear that hospitals would pass along the charges to patients.

Under the rules, the charges CAN NOT be passed along to the patient.

Common Errors and Infections. There is no indication exactly how the program will determine which fees are the results of preventable errors.  However, it does look like certain issues will be considered “per se” error, such as bed sores, bladder infections resulting from catheters, and preventable infections such as those stemming from staphylococcal infections.

The rule identifies eight conditions — including three serious types of preventable incidents sometimes called “never events” — that Medicare no longer will pay for. Those conditions are:

• Objects left in a patient during surgery
• Blood incompatibility
• Air embolism
• Falls
• Mediastinitis, which is an infection after heart surgery
• Urinary tract infections from using catheters
• Pressure ulcers, or bed sores
• Vascular infections from using catheters
• The Centers for Medicare and Medicaid Services said it also would work to add three more conditions to the list next year.

$20 Million Dollars Worth of Malpractice.  The Bush administration expects this will save $20 million per year, which to me means there is $20 million per year worth of treatments designed to “fix” malpractice.  You can count this as one of the first times this Administration has recognized the prevalence of medical negligence.

Implications for Attorneys.  The implementation of this policy only seems to have positive implications for victims of malpractice.  The most obvious would be that if Medicare does not pay for these services, then there can not be a lien from recovery.  I would suppose that if one gets a verdict or settlement on a malpractice claim that if Medicare has paid, the attorney for the patient could argue that Medicare should receive a refund from the medical provider rather than a lien against the Plaintiff’s recovery.  Right now I don’t know the effective date of the policy change.

I will be doing further research to see how the regulations will be implemented.  I’m assuming that Medicare’s refusal to pay for “malpractice” will not be admissible to prove negligence in malpractice cases.

A further question is what happens when the victim of malpractice needs medical treatment for the remainder of their lives?  Will the hospital be paying for all the bills?  I’m thinking this will be a difficult issue in some cases.

Check back for updates on this post.

Chris Nichols
www.NicholsTrialLaw.com

Honestly, I have no idea if this is “good” or not, but it averages out to about 30 new visits per day, so I think in general, it’s been a good thing.

For those very few that subscribe to an RSS feed, sorry I’ve not been posting a whole lot lately. I had a month long trial in Charlotte, back in March, and that kept me pretty busy for the two months before, and the two months after.

I’ll be posting some new lien resources in the next few weeks, and I’m working on a neat little software package that might just help the lawyers out there.

As always, send me your suggestions by email to nicholsatty@gmail.com, if you have them.

Chris Nichols
www.NicholsTrialLaw.com