WorkCompCollege.com Study Hall Sept. 2024

Heather Schwartz Sanderson is a nationally recognized legal expert in Medicare Secondary Payer (MSP) Compliance. With over 15 years of experience, she provides cutting-edge legal expertise, practical analysis, and expert technical guidance to the Property & Casualty Insurance market and legal communities. In 2021, Heather founded Sanderson Firm PLLC, committed to MSP compliance solutions and service excellence. Previously, she served as Chief Legal Officer for Franco Signor and contributed to MSP legislative reform in Washington D.C. 

(1) Why did you choose this subject matter to teach? 

As of April 2024, there are more than 67 million individuals across the United States enrolled in traditional Medicare (Medicare Parts A & B), Medicare Advantage (Medicare Part C), and Medicare Prescription Drug (Medicare Part D) plans. When these individuals file workers’ compensation, general liability, and/or no-fault insurance claims, multiple Medicare Secondary Payer (MSP) legal obligations may be triggered affecting the injured claimant, insurance carrier, employer (if workers’ compensation claim), and attorneys. Despite the incredibly large population of Medicare beneficiaries and well-established MSP legal obligations, there are very few resources available covering all aspects of MSP compliance – namely, Medicare conditional payment obligations, Medicare Set-Aside obligations, and Medicare Section 111 reporting obligations. MSPA serves industry stakeholders by being the only fully on-demand, virtual MSP training course covering all areas of MSP compliance taught by experts currently in the field. MSPA is a “one-stop shop” for all conceivable MSP issues. 

(2) Why is this subject matter important to Work Comp stakeholders? 

The Centers for Medicare & Medicaid Services (CMS), the federal agency tasked with administering the Medicare program, continues to advance Medicare Secondary payer policies, regulations, and rulemaking year-over-year. Beginning in October 2024, Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) will be subject to civil money penalties of up to $365,000.00 (plus inflation) for each untimely reported Medicare beneficiary record as required by the Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007. Additionally, for the first time ever, NGHP RREs will be required to report Workers’ Compensation Medicare Set-Aside information to CMS through Section 111 reporting beginning in April 2025. All signs point to continued increase in CMS enforcement and penalties for noncompliance with MSP mandates. Workers’ compensation stakeholders will exit the MSPA course confident in their abilities to successfully navigate the complex MSP landscape and avoid costly penalties and potential litigation from the federal government and private insurance companies. 

(3) How does your content help further a workers’ recovery mindset? 

Competent resolution of all MSP issues (Medicare conditional payment reimbursement, Medicare Set-Aside funding, and Section 111 mandatory insurer reporting) will ensure that all parties to the workers’ compensation settlement (including the injured worker) are protected against governmental claims post-settlement and potential termination or interruption of the injured worker’s Medicare benefits. This will alleviate concerns outside the scope of recovery and physical healing as the injured worker exits the work comp system. Furthermore, a Medicare Set-Aside allows the injured worker to set-aside an appropriate amount of funds for their future medical care while also allowing the insurance carrier to efficiently close out the future medical component of the workers’ compensation claim. This provides peace of mind that future care will not be impeded by finances. For insurance claims professionals, the MSPA course will equip them with the appropriate knowledge to identify a Medicare beneficiary or reasonable expectation claimant and allow the claims professional to satisfy Medicare’s interests in the workers’ compensation settlement. 

(4) What are five takeaways / action items for students? 

1) Understand foundational Medicare Secondary Payer principles, case law, and why compliance is necessary 

2) Identify, negotiate, and resolve Medicare conditional payment liens disputes 

3) Assess the appropriateness of a Medicare Set-Aside, including submission and non-submission to CMS 

4) Monitor compliance with Section 111 reporting obligations considering the potential for $1,000 in civil money penalties per day for each mishandled Medicare beneficiary record 

5) Understand the importance of continued MSP compliance education in this ever-evolving landscape 

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