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October 2015 Newsletter
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NAMSAP Quarterly Newsletter 
Volume 8, Number 3                                                                                     October 2015
By:  Kimberly A. Wiswell
President, 2015

        Director of Operations, MEDVAL

We're two weeks past our Annual Meeting which took place in New Orleans this year. I wanted to extend our thanks and appreciation to everyone who was able to join us for our meeting and conference. Despite some challenges with the hotel (we were located on Bourbon Street after all!), it was a successful conference and everyone seemed to enjoy both the programs and the location, as well as the dual track format and three-day schedule. I would also like to again thank our Annual Meeting sponsors for their support – we couldn’t do it without you!

KP Underwriting
EPS Settlement Group
FIG Services
Franco Signor
LASIE (Louisiana Association of Self-Insured Employers)
Rising Medical Solutions
Work Loss Data Institute - Official Disability Guidelines (ODG)

We’re headed into the home stretch of this year and the holidays will be upon us shortly. As part of our year-end activities here at NAMSAP, we’ll be holding elections for the Board of Directors. To nominate yourself or someone else, please use the following link: Please have your nominations submitted by Friday, October 30th. Voting will begin on Monday, November 9th and run through Friday, December 4th. A link to the ballot will be distributed to all voting eligible NAMSAP members, with installation of the successful candidates as board members on January 1, 2016.

We’ve added a new feature to your online membership renewals for next year, which will allow you to sign-up for committees of interest to you. We encourage your participation – “many hands make light work,” as the saying goes, and most members feel they receive more value out of their NAMSAP membership through participation in one of our committees.

In closing, thank you so much for your support over this past year. I wish you all the happiest of holidays over the coming season.

Warm regards,

By:  Heather  Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP 
       Chief Legal Officer, Franco Signor, LLC

The Medicare Advantage Plan (MAP) system continues to grow; according to the Kaiser Family Foundation, as much as 31% of the Medicare population in the United States is also enrolled in a Medicare Advantage Plan. Recently, we have seen a great deal of case law where courts have had the difficult to task in deciphering whether MAPs and MAP beneficiaries can seek to benefit from the MSP private cause of action, 42 USC §1395y(b)(3)(A), which was previously only thought to exist for traditional Medicare conditional payment recoveries. Also, a continued discussion and debate is whether MAP plans should be considered as part of the traditional Medicare system or whether they should be treated like private insurance plans. The ultimate determination as to whether these plans are to be considered to have the same rights and role of traditional Medicare or not has an extremely meaningful effect on rights under the MSP.

In a recent opinion out of the United States District Court for the Eastern District of Tennessee, Cariten Health Plan, Inc. v. Mid-Century Insurance Company, 2015 U.S. Dist. LEXIS 126887 (September 1, 2015 decided; September 24, 2015 published), we have another example where a Medicare Advantage Plan (MAP) has sought to establish its right to an MSP private cause of action (PCOA) for double damages against a non-group health plan (NGHP) which allegedly failed to pay as a primary plan and where the MAP made conditional payments. Cariten Health Plan (“Cariten”), a MAP, was granted the ability to pursue an MSP PCOA for double damages against the no-fault insurance carrier, Mid-Century Insurance Company (“Mid-Century”) pursuant to 42 USC §1395y(b)(3)(A).

Cariten alleged in its Complaint that when an individual who has enrolled in one of its Medicare Advantage Plans is also eligible to receive payment for medical expenses pursuant to an insurance policy with Mid-Century, then Mid-Century becomes a primary medical benefits payer and Cariten becomes a secondary payer by operation of federal law. Despite this, Cariten alleged that Mid-Century routinely refused requests by Cariten for Mid-Century to make primary medical expense payments, or to reimburse Cariten for medical expense payments that Cariten has made prior to learning that Mid-Century in fact had a primary obligation to make the payment.

Cariten specifically cited one of its enrollees, referred to in the decision as “Enrollee 1,” where it made over $55,000 in conditional payments and Mid-Century failed to reimburse these payments as primary payer. Cariten initiated this action seeking a declaration that the no-fault insurance coverage issued by Mid-Century is primary to Medicare benefits advanced by MAPs such as Cariten, and that when an MAP such as Cariten has advanced benefits in which its payments are secondary to Mid-Century’s payment obligations, Mid-Century is obligated to make appropriate reimbursement to the MAP. Ironically, Mid-Century did not dispute being a primary payer for Enrollee 1, even though no settlement, judgment or award had been issued for Enrollee 1. Cariten also claimed that it was entitled to double damages from Mid-Century for the payment of $15,799.43 it made to discharge Enrollee 1's medical bills, pursuant to the private right of action provided by 42 USC §1395y(b)(3)(A) or in the alternative, recovery of the entirety of the $55,378.70 in charges submitted by Enrollee 1's medical providers, pursuant to a Federal common law right of action.

Cariten brought three counts within its Complaint: 1) an MSP PCOA pursuant to 42 USC §1395y(b)(3)(A) or in the alternative a Right of Action under Federal Common Law; 2) a Claim for Restitution or Unjust Enrichment; and 3) a Claim for an Accounting. Mid-Century filed a Motion to Dismiss the Complaint, and the Court ultimately granted Mid-Century’s Motion to Dismiss all counts, except for only the MSP PCOA pursuant to 42 USC §1395y(b)(3)(A). For the purposes of this blog, only the remaining count which Cariten is allowed to pursue, the MSP PCOA, will be discussed.

In deciding whether to allow Cariten’s MSP PCOA pursuant to 42 USC §1395y(b)(3)(A) to proceed, the Court looked to the In Re Avandia case, and found it to be persuasive. As the court in Avandia noted, the term "subchapter" refers to the entire Medicare Statute, including Part C governing MAPs. Therefore, as cross-referenced in the "[o]rganization as secondary payer" provision of Medicare Part C, 42 U.S.C. § 1395w-22(a)(4), the language of § 1395y(b)(2)(A)applies to MAPs. Additionally, the private right of action provision of § 1395y(b)(3)(A) specifically refers to the secondary payer scheme by citing paragraph (2)(A), but not the conditional payments scheme of paragraph (2)(B). Thus, § 1395y(b)(3)(A) provides a private right of action that extends to MAP plans for violations of § 1395y(b)(2)(A). Therefore, since § 1395y(b)(3)(A) provides Cariten with a Federal right of action, Cariten may proceed and has a plausible claim for relief.

This decision is monumental as we now essentially have three Circuits in agreement on this issue. Recall that in the case of In Re Avandia out of the Third Circuit, a MAP was granted the right to the MSP PCOA (the writ of certiorari of this case to the U.S. Supreme Court was denied). Additionally, Humana Medical Plan v. Western Heritage case out of the U.S. District Court for the Southern District of Florida (11th Circuit), granted Humana the right to an MSP PCOA, although the case is currently on appeal at the 11th Circuit (oral arguments are expected early 2016). This decision, Cariten, out of the Sixth Circuit, now brings the tally to three Circuits allowing the MSP PCOA to proceed by a MAP against an NGHP. However, we do have one Circuit that has disagreed. Recall that previously in the Ninth Circuit in the Parra v. PacifiCare of Arizona case, a Medicare Advantage Plan was denied the right to the MSP PCOA.

The tide seems to be heading in favor of MAPs having the same rights as Medicare as we now have three Circuits in agreement on this issue. Of course we will wait to see what happens with the Western Heritage case and what courts decide in other jurisdictions, but as of now, it is becoming abundantly clear that NGHP payers need to be cautious where a MAP has made conditional payments and is seeking reimbursement. Prompt reimbursement of these payments to the MAP will avert an MSP PCOA for double damages; MAP conditional payment demands should not be ignored.


Rita M. Wilson
       CEO, Tower MSA Partners, LLC

Effective October 5, 2015, as part of the continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, the Centers for Medicare & Medicaid Services (CMS) has transitioned a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). The CRC has assumed responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity as the identified debtor. In other words, the CRC will identify and validate recoverable conditional payments, issue conditional payment notices (CPNs) and demand letters, respond to disputes and appeals, receive payments and resolve outstanding debts, and refer delinquents debts to the Department of Treasury (DOT) for further collection actions.

What Claims Are Being Transitioned?

According to CMS in its October 5, 2015 What’s New Release, the transition to the CRC is a workload transition impacting the recovery process as follows:
  • The transition only includes new cases where CMS seeks recovery non-group health plans (NGHPs). Actions pending prior to October 5, 2015 will continue to be managed by the BCRC.
  • Beneficiaries and their attorneys will continue to work with the BCRC where CMS is pursuing recovery from the beneficiary.
  • All other entities will continue to work with the contractor from which you received correspondence, either the CRC or BCRC.
The CRC will manage cases where the Responsible Reporting Entity (RRE) has reported Ongoing Responsibility for Medical (ORM), ORM Termination or Total Payment Obligation to Claimant (TPOC) on Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and CMS has identified the primary debtor as the RRE.

What Are the Expected Changes?

One of the biggest changes is in the initial dispute process. Where the BCRC provides a Conditional Payment Letter (CPL), the CRC will issue a Conditional Payment Notice (CPN). Both are information — not requests for payments. Both identify the amount of the current conditional payment, provide a statement of reimbursement, and describe the manner for disputing the charges. As we understand CMS’s communications as of today, the key difference in workflow between the CPL and CPN is the action that must be taken upon receipt of the notice. Where the CPL has no specific date for a response, the CPN must be disputed within 30 days. Failure to do so will result in a demand letter or initial determination issued to the applicable plan for payment. While applicable plans do have appeal rights for recovery demand letters issued on or after April 28, 2015, the demand letter locks the applicable plan in place as the identified debtor. Also, interest accrues from the first day of a demand letter; however it will not be assessed if the debt is paid within 60 days.

How Will the CRC Process Work?

The CRC will begin to issue CPNs starting October 25, 2015 from Section 111 data processed on or after October 5. The expected process is as follows:
  1. When an NGHP Responsible Reporting Entity reports acceptance of Ongoing Responsibility for Medical (ORM) through its Mandatory Insurer Reporting (MIR) process, if there are payments Medicare believes to be attributable to the reported injury, the CRC will issue a CPN.
  2. The CPN will be sent to the company / TIN listed as Recovery Agent (new data elements added to the S111 Reporting dataset effective 10/5/15). If Recovery Agent isn’t populated, the default entity to receive the CPN will be the S111 Reporting Agent.
  3. The CPN will include conditional payment information on a Statement of Reimbursement that lists payments made by Medicare in which it seeks reimbursement. The letter will also indicate instructions as to how to proceed.
  4. The CPN is NOT a request for payment. However, the applicable plan (AP) that receives the letter has 30 days from the date of the CPN to dispute or respond to the alleged conditional payment.
  5. If no dispute is received following the CPN, or if after the negotiation, the Statement of Reimbursement still contains services paid by Medicare, the CRC will issue a demand letter.
  6. The demand letter will describe information relating to the case, update the Statement of Reimbursement (to include any additional payments made since issuing CPN) and include an explanation of how to appeal any items on Statement of Reimbursement.
To dispute the CPN, the applicable plan may contact the CRC in writing or through the Medicare Secondary Payer Recovery Portal (MSPRP). However, disputes submitted through the portal may only be on the basis of relatedness and in response to a CPN. All other disputes must be in writing.

Applicable plans will have one opportunity to file a dispute. If the CRC does not agree with the dispute the conditional payments will be reflected in the demand letter.

Early Feedback on BCRC vs. CRC

As we are past the initial date of October 5 for the implementation of the CRC yet before the start date for the issuance of CPNs, there remain many unanswered questions as to the relationship between BCRC and CRC. Early feedback obtained from certain of our membership includes the following:

  • At present, calls may not be made directly to the CRC. Calls must be made to the BCRC and a request to transfer to CRC would then be requested.
  • An attorney or vendor cannot speak to the CRC unless it is the entity listed as ‘Recovery Agent’ as submitted in the S111 reporting dataset. The default entity appears to be the INSURER.
  • The BCRC will not provide a Case ID# to anyone other than the S111 Recovery Agent, even if the requesting entity has Proof of Representation.
  • A faxed request may be sent to the BCRC on the requester’s or letterhead to request the Case Id#. According to information received from the BCRC, this may take up to 45 days.
  • After 45 days anyone can call the BCRC to request the Case ID#.

What Steps Should be Taken Now?

To prepare for successful transition when CPNs arrive beginning October 25, 2015, workers' compensation payers can help prepare for a smooth transition by taking the following actions:

  • Verify the name, address and TIN (tax identification number) of the entitiy you wish to designate as Recovery Agent in the new data fields added to S111 reporting requirements effective October 5, 2015. This is the entity that will receive the CPN.
  • Ensure Section 111 reporting information is updated.
  • Make sure the ORM process is working properly.
  • Continue to report new claims to the BCRC as early as soon as a positive query response is received.
  • Carefully review all correspondence related to conditional payments to determine if they are generated by the CRC or BCRC and follow up with the appropriate entity.
  • Develop and implement a process for the timely review of CPNs as well as CPLs.
  • Make sure disputes of CPNs are properly filed within the 30-day time limit.
As we move forward, NAMSAP will continue to track CMS News Alerts and to poll individual companies to assess actual experiences. In the meantime, questions should be directed to your Section 111 Reporting Agent and workflow management should be established and coordinated with the designated Recovery Agent.


Marci Morehead, RN, CRRN, CLCP, CRP, CMAS, MSCC
It’s now been almost three weeks since the implementation of ICD-10 and I have not heard any reports of allocator fatalities! As we have all heard over and over, ‘ad nauseum’, ICD-10-CM is the diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all United States (U.S.) health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM. The system is designed to better accommodate the rapidly changing world of diagnoses, flexible enough to quickly incorporate emerging diagnoses, and exact enough to identify diagnoses precisely. For example a patient fractured his left wrist at work and month later, fractured his right wrist in a non-related incident. The ICD-9 code does not identify left versus right and requires additional documentation. The ICD-10 code describes that it’s left versus right, is it an initial encounter, subsequent encounter, or sequelae encounter; and is it a routine healing, delayed healing, nonunion, or malunion.

The increased code detail contained in ICD-10 means that clinical documentation will change with a more detailed description of a patient’s condition including severity, co-morbidities, complications, manifestations, and causes. In general ICD-10 will improve healthcare overall (patient and provider). By incorporating much greater specificity and clinical information, it will improve the ability to measure health care services, increased sensitivity when refining grouping and reimbursement methodologies, enhancing the ability to conduct public health surveillance, track treatment outcomes, and decrease the need to include copious amounts of supporting documentation with claims.

While Workers Compensation is an exempt entity along with Property & Casualty Insurance Plans and Disability Insurance Programs there are numerous benefits for voluntary compliance. CMS plans to work with non-covered entities to encourage ICD-10 use as they feel that would be in their best interest to adopt these code sets. The increased detail in ICD-10 provides significant value to non-covered entities. ICD-9 will no longer be maintained now that ICD-10 has been implemented meaning the usefulness of the ICD-9 code set will rapidly decline. Those non-covered entities that continue to use ICD-9 after the ICD-10 October 1st will compromise their ability to compare data with covered entities.

What’s the Impact on Medicare Set Asides?

For those who prepare Medicare Set Asides, ICD-10 brings proper, concise medical documentation. Codes are more specific and reduce the need for applying more than one code to a diagnosis or procedure. Codes paint a better picture of the claimant’s current medical status and reduce the risk of inaccurate recommendations due to typos in the providers’ reports. This is essential for a provider. The more accurate and precise the coding the more likely the provider will receive maximum payment in the least amount of time. Trust me there is incentive for them to get this right first! So reports will be shorter, yet contain better information. How many times have you read a ten page medical report where the provider referred to the injury of the foot back and forth as left and right? How many times have you read a report that had regurgitated information that was actually no longer accurate or the condition had resolved? That will end as the coder will not be able to sufficiently code the claim with that misinformation. Therefore it is likely that those reports will be corrected before they even leave the provider’s office.

So what else does that mean for us? The new coding system improves the ability to project medically necessary and reasonable future treatment because the medical records are more precise with regards to current condition and recommended treatment especially in the case of a compensable complication. It will improve the turnaround time for approval of the allocation because of code alignment. And the uniformity with all health insurance groups will improve the ability to appropriately price future care based on a more accurate description of the claimant’s injuries.

What Does ICD10 Require? There are basic documentation requirements for ICD-10. Each unique ICD-10 diagnosis code may be reported only once for an encounter. For bilateral conditions the final character of the code indicates laterality. This means that the records should be accurate with regards to the body part and side. To be considered a complication of a condition and/or procedure, there must be a cause-and-effect relationship between the condition, the care provided, the resulting complication, and an indication in the documentation that there is a complication. This means that the provider must establish a specific relationship to the injury itself. Hopefully this will rid us of those pesky “kitchen sink” cases.

Signs and symptoms can no longer be used as a principle diagnosis when a definitive diagnosis has been established. The code for the symptom(s) will be required to remove and replace with the definitive code. Secondary diagnoses/other diagnoses will be listed as additional codes that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended hospitalizations, increased need for care, and/or monitoring. Therefore any claims of internal disorders such as an aggravation of hypertension will require extensive documentation as to how this disorder is impacted and/or caused by the injury. It also identifies diagnoses that could delay healing and may help explain the need for management of a certain disorder such as diabetes during the pre/peri/post-injury/operative stages.

Diagnoses that relate to an earlier episode that have no bearing on the current condition are to be excluded. All resolved diagnoses or diagnoses/status post procedures that have no bearing on current treatment are not to be reported. If the claimant injured his right shoulder, has completed treatment, and requires no further treatment then this would be removed from the medical record. Thus we would be able to document in the allocation that this condition was removed from the medical record and does not require future treatment. Remember these requirements were set up by CMS and should be honored if we can produce the proper documentation. Test findings are not coded or reported unless the physician indicates the clinical significance and any need for treatment. Documentation for injuries such as fractures has additional documentation and coding requirements.
In ICD-10 approximately 50 percent of all codes are related to the musculoskeletal system, and 25 percent are related to fractures. As such, the need for further clarification is essential to proper code assignment. ICD-10 fracture codes can specify the fracture type, such as greenstick, the specific anatomical site, displacement status, laterality, routine versus delayed healing, nonunions, and malunions. Of these new choices, laterality and type of encounter are significant components for the code expansion. Some fracture categories also include that seventh character extension to designate the type of open fracture. This would allow us to determine a clear picture of what the claimant will need long term.

How Should We Get Started?

So where do we start with coding our allocations. I would recommend at least in the first year that we all start requesting the most recent HCFA 1500 claim forms which would have the most recent diagnoses codes. If those are not available then code the claim from the most recent medical record for each specialty. What do we do to ensure that our codes are the most accurate? Purchase any one of the “official” ICD-10 coding book sets. Since we have no idea how stringent CMS will be about the coding used in our allocations it is important that we try to keep them as accurate as possible.

Remember that there is NO one-to-one match despite the information found on the internet. These codes were never intended to be a 1:1 code match. Many codes translate to clusters (groups). If there were a one‐to‐one match/crosswalk between the two classification systems then there would be no need to convert ICD‐10. The challenge for CMS was to find the closest equivalent codes that map between the two systems. There are software programs and vendors who can provide General Equivalence Mappings (GEM) and these are wonderful resources. However it is recommended that you purchase the ICD-10 coding books. It’s the best way to ensure that you are coding your allocation properly. Keep calm and code me ICD-10 will improve our ability to prepare the most accurate allocation that considers Medicare’s interest and provides a realistic view of the claimant’s future needs.

Rasa Fumagalli, 
        Director of Compliance and Quality, Protocols

NAMSAP’s Annual Meeting this year included a lively discussion of the relationship between state workers’ compensation law and the Medicare Secondary Payer (MSP) law. The discussion was led by Jennifer Jordan of Medval, LLC and Danielle Marone of Schmidt, Dailey &  O’Neill, LLC. Their combined experience in the areas of structured settlements, MSP compliance and work for CMS’ WCMSA review contractor and perspectives fostered a well-balanced consideration of the conflict between the two laws. For those who were unable to attend the presentation, the following is a brief review of the covered material and topic.

The presentation began with an overview of the powers granted to the United States government and those reserved to the states by the Constitution and Amendments to it. Although federal law will generally supersede state law, states have the right to establish their own laws pertaining to areas that are not specifically reserved for the federal government. Since there is no national federal workers’ compensation law, each state has the authority to enact its own workers’ compensation law.

An employer’s responsibility to pay in any given claim, as well as the extent of the responsibility, may at times be interpreted differently by the state workers’ compensation law and the MSP law. State workers’ compensation laws generally require an employer to pay for “reasonable, necessary and related” medical treatment once the employee proves he or she sustained a compensable injury that “arose out of” and “in the course of” their employment. The MSP law, 42 U.S.C. 1395y(b)(2)(A)(ii), prohibits payment by Medicare when “payment has been made or can reasonably be expected to be made under a workmen’s compensation law or plan of the United states or a State or under an automobile or liability insurance policy or plan (including a self-insured plan) or under no fault insurance.” The differing interpretations of the payments “to be made under a workers’ compensation law” are most evident when a settlement closing out future care includes a Medicare Set-Aside (MSA) intended to prevent a cost shift of the future care to Medicare. CMS, when asked to review the MSA, will often include inflated future care projections in their determinations. The inflated figures are partly due to CMS ‘ use of the Average Wholesale Pricing for the drugs, pricing of projected surgeries based on the most expensive facility in the area, excessive diagnostic projections and projection for care that is unlikely to occur in the claim. CMS’ review of the future medical allocation is also driven by its desire to preserve the Medicare Trust Fund.

Given CMS’ motivation and the purely voluntary nature of the CMS MSA review process, the parties to the settlement should carefully assess whether the benefits of CMS submission outweigh the risk associated with the likely return of an overinflated WCMSA determination. If CMS review is pursued, applicable state law arguments and supporting documentation should be presented to CMS. Final Court Orders issued after “hearing on the merits” should be given deference by CMS. When enforcement of a state workers’ compensation law may conflict with the MSP law, the federal law may implicitly preempt the state law. Georgia’s Workers’ Compensation Act that includes a 400 week cap on benefits was cited as a possible example.

The presentation concluded with a reminder that when a settlement provides sufficient funds for future injury related care, the cost will not be shifted to Medicare. In light of this, there is no need to overfund an MSA. Should CMS issue a determination that will be disregarded, the settlement terms should outline the rationale for disregarding it and incorporate it into the state approved settlement. State law is the law that should control settlement value, not the MSP law.

Tom Matson, CMSP
       Vice President, Client Development
       Gitter & Associates

The 11th NAMSAP Annual Meeting and Educational Conference took place from September 30 – October 2, 2015 at the beautiful Royal Sonesta Hotel in the heart of New Orleans, LA. The festivities kicked off with three pre-conference sessions that gave attendees an added opportunity to obtain their valuable continuing education credits, and continued that afternoon with the general conference kickoff. Upwards of 150 attendees descended onto The Big Easy for three full days of educational seminars and networking opportunities. Consistent with NAMSAP’s support of the use of Evidence Based Medicine (EBM) guidelines in projecting future medical needs, several of the presentations this year discussed the application of these guidelines to specific injuries and opioid use. The information relayed by our panels of experts will undoubtedly equip our members with additional tools and resources needed to further encourage the implementation of these guidelines at CMS. Additionally, NAMSAP was able to hold Legal and Allocator Breakout Sessions that allowed the presenters to dive deep into their topics and interact on a more personal level with the attendees. These sessions offered up much more detail than what can typically be given during a general session. Rounding out the event, panelists from across the country presented on topics ranging from the always-controversial Liability MSAs, to the Affordable Care Act and Its Effect on MSAs, to Perspectives on MSP Compliance from the end user. The Annual Meeting Subcommittee again worked tirelessly to provide a wonderful conference, and is already hard at work in the planning stages for 2016. Be on the lookout in the coming weeks for information on next year’s conference as it will surely be another you will not want to miss!

To check-out some photos from the 2015 Annual Meeting & Educational Conference please click here!

Committee News

Webinar Subcommittee
By: Shawn Deane, MSCC, CMSP
      Assistant Vice President, Product Development 
      ISO Claims Partners

  • On August 18th we held a webinar on the ICD-10 transition. Fran Provenzano, Leslie Schumacher and Marci Moorhead presented. NAMSAP Board member and webinar subcommittee chair, Shawn Deane, will be holding a NAMSAP webinar on the Commercial Repayment Center (CRC) and CMS’s new recovery procedures. We are currently solidifying a date, but it will be some time in November. NAMSAP Board member and webinar subcommittee chair, Shawn Deane, will be holding a NAMSAP webinar on the Commercial Repayment Center (CRC) and CMS’s new recovery procedures. We are currently solidifying a date, but it will be some time in November. The EBM committee will be setting a date shortly on their second EBM webinar. The first one was a great success with many attendees and the second is going to be just as good so keep an eye out. The Webinar Committee would like to solicit interested NAMSAP members to participate as a member. Please contact Shawn Dean at for more information on participation.

Regional Meeting Subcommittee
By: Doug Shaw, CPA, CMSP

I am very excited to announce that the board has decided to host a Regional Meeting in Spring 2016. Last year we were in Orlando and the previous year in Miami. We are quickly in the process of deciding a date and location and will update the membership as soon as possible. In addition, the subcommittee also hopes to release details on the format, topics, speakers, etc. in the near future.

Please stay tuned for more details to come!

By: Ciara F. Koba, Esq.            
      Associate, Medicine Compliance Group
      Burns White Attorneys at Law

The Legislative Committee is working to follow up on its efforts to encourage CMS’ implementation of a formal Re-Review process for WCMSAs submitted to CMS for approval. The Committee meets on the third Tuesday of every month and has been working with offices in both the House and Senate to finalize a letter to be sent to CMS regarding implementation of a Re-Review process, if needed, to facilitate CMS’ adoption and publication of revised Re-Review guidelines. We are always looking to include additional members on the Committee.


By: Fran Provenzano, RN, BSN, CDMS, CCM, CLCP, MSCC, CMSP
      Medicare Set-Aside Specialists, Inc.

The DDC was well represented at the 2015 Annual Meeting in New Orleans. Sandra Mackler and Debbe Marcinko were outstanding discussing the latest trends and global pricing of procedures and medications extrapolated by our committee.

The DDC will continue to track outlier pricing of medications and services as well as focus on physical therapy frequencies and associated costs.

We look forward to new members and provide this as an open invitation to join our committee.


By: Emily Grocoff, CMSP, MSCC
      Manager of Allocation Services

In October, NAMSAP staff with oversight of the Membership Committee, recently invited lapsed members (2013 and 2104) and nonmember Annual Meeting attendees to join for the current rate of $175 and receive 15 months of membership. If you know of someone who would benefit from this discount and isn’t a current member, please provide them the following promotional code to use when joining online: 15FOR12AUG2015.
Currently within NAMSAP's membership, there are twenty Partner Professionals. Partner Professionals help support significant events and programs and contribute gifts and in-kind services that enrich the overall quality of services NAMSAP can provide to its members. In return, Partner Professionals have privileged access to the influential members of our community.

The NAMSAP Listserv provides an open forum for discussion of any Medicare Set-Aside issues professional and associate level members would like to discuss. To have your email added to the Listserv, please email Membership Coordinator Lisa Kennelly at


The NAMSAP Communications Committee would like to encourage you to submit an industry-related article for our upcoming newsletter. We are accepting submissions in the following categories: Legal, Legislative, and Medical. If you are interested in contributing to one of these categories, or have an idea for a new category, please contact Rita Wilson, Communications Committee Chair. She can be reached by email at

Click here for past Newsletter editions!

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