Audit and Resolution of Government and Private Healthcare Liens
In nearly every case, the settlement of a physical injury claim requires the resolution of one or more healthcare liens. A portion of a claimant’s settlement may be owed to the claimant’s health insurer, whether it is a private provider, or a government provider such as Medicare, Medicaid, or the Veterans’ Administration.
Depending on settlement terms, applicable state and Federal laws, and American Bar Association model rules, plaintiffs’ and defense counsel could have obligations to provide certain information to providers, as well as to facilitate payment of a portion of settlement proceeds to primary payers. Inadequate compliance with the maze of healthcare lien rules exposes plaintiffs, defendants, counsel and insurers to a variety of financial and regulatory risks.
In each case, attorneys must determine the following for each of their clients:
- Does the claimant’s health plan have a reimbursement interest for past as well as future injury- related care?
- Given the nature of the claimant’s recovery, is full reimbursement appropriate?
- As an attorney, what are my obligations to notify and facilitate payment in this settlement?
- What defenses, compromises, waivers or offsets are available to maximize the claimant’s award?
In mass tort / class action and individual (single event-cases), GRG’s lien resolution team specializes in determining what obligations each party bears in notifying and paying providers. This service helps attorneys to ensure they are meeting their professional obligation to their client, and keeping the client in good standing with their healthcare provider. It is crucial that an attorney properly identify and resolve any obligations to a healthcare provider that are part of settlement, because failure to resolve a lien can result in the revocation of a claimant’s eligibility for healthcare coverage.
In utilizing GRG’s Healthcare Lien Resolution services, attorneys are spared the onerous responsibility of determining obligations to pay healthcare providers, and are able to focus on their core responsibility: advocating for their client.
GRG’s Health Care Lien Resolution team is knowledgeable and experienced in working through the unique responsibilities brought forth by each claimant, in both individual (single-event) and mass tort claims.
GRG Healthcare Lien Resolution Capabilities
Firms rely on GRG again and again, knowing that others can’t compare with GRG’s capabilities. Clients find extensive value in GRG’s value-added services, such as:
- Compliance and resolution programs designed in consultation with client to ensure appropriately robust protocols and clear allocation of responsibilities among in-house staff, GRG and other outside advisors. Access to GRG subject matter experts for advisory support in out-of- the-ordinary cases.
- In-depth educational training to client staff and outside counsel on Medicare, Medicaid and private lien (including Medicare Advantage) obligations, with periodic updates to cover changes in law and evolutions in administrative best practices
- Reporting and updating protocols customized to client preference for monitoring individual case status and specified program metrics
- Medicare reporting via integration with client’s existing claim management systems to receive, compile, and transfer relevant data points
- Full Future Medical Allocation services available in situations where settling a dispute requires escrow of funds to pay future medical expenses otherwise covered by Medicare
Scope of Services
In each case, GRG’s Healthcare Lien Resolution service:
- Determines the settling parties’ affirmative obligation to notify healthcare plans
- Assesses the healthcare plans’ right of recovery, determining what portion of settlement proceeds to which healthcare plans are entitled
- Audits and analyzes each reimbursement claim to determine accuracy and to “carve out” items unrelated to injury/settlement
- Pursues relevant administrative remedies, such as damage allocation, waiver, and compromises to ensure the appropriate “net” recovery for the claimant
- Handles other healthcare issues related to settlement, such as Future Medical Allocation and MSA Custodial Account Services
GRG works to resolve healthcare liens asserted by the following entities:
- Medicare Parts A and B. If Medicare has paid for any treatments related to an injury covered by the settlement, federal law gives Medicare the first right to recover some or all of the payments. Additional payers, if any, must wait until Medicare’s interests are satisfied.
- Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA) was enacted in 2009 and took effect in 2010, significantly changing resolution obligations. Under the MMSEA, the defense (or responsible party) must report certain information about settlements involving Medicare beneficiaries to Medicare. When it comes to Medicare reporting, the key to avoiding major disruptions in your cases is to start early and start right.
- Medicare Part C. This includes healthcare coverage that is a replacement for Medicare Parts A and B. Medicare Part C plans are typically provided by a private insurer.
- State Medicaid. Every American state and territory has its own Medicaid agency, and each has its own set of regulations. Medicaid’s right of recovery is similar (but secondary) to Medicare’s.
- Military or Other Governmental Healthcare. If a client has healthcare coverage through the U.S. Department of Veterans Affairs (VA), TRICARE, Indian Health Service (IHS), or another government agency, and if that entity has made healthcare payments on her behalf as a result of the litigation-related injury, then the agency may be entitled to recovery.
- Private Insurers. A private healthcare insurer may be entitled to recovery in the same manner as a government payer, but the insurer’s right of recovery depends on the plan’s contract language and the laws of the state in which it operates, or in some cases federal law.
- Others. If a client receives medical benefits through any other type of health plan, GRG can notify the plan and determine whether it has any legal interest in the settlement.