Category Archives: Pharma Part D

Blog, Medicare Secondary Payer News, Medicare Set Aside, Pharma Part D, WCMSA

What is the intended purpose behind a Workers’ Compensation Medicare Set-Aside (WCMSA)? The WCMSA Reference Guide, Section 3.0 states: “A WCMSA allocates a portion of the WC settlement for all future work-injury-related medical expenses that are covered and otherwise reimbursable by Medicare (“Medicare covered”) (emphasis added). Accordingly, Medicare through its issued guidance has provided that medical expenses should not be …
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Blog, Medicare Secondary Payer News, Pharma Part D

Recently, CMS updated its Part D Manual to include specific changes to the Manual’s Medicare Secondary Payer (MSP) provisions.  The updated manual can be found here. Page 40 now provides: “Part D sponsors are responsible for adjudicating enrollees’ claims in accordance with MSP requirements. Under CMS’ adjudication logic for Part D MSP claims, the provider/pharmacy receives at least the Part …
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Blog, Medicare Advantage Part C, Pharma Part D, Trial Practice

A new decision was handed down from the U.S. Court of Appeals for the 11th Circuit in the Barbara J. Harvey v. Florida Health Sciences Center, Inc. this month.  Here, the Plaintiff pursued a medical malpractice claim against a hospital for her husband’s death.  The hospital agreed to binding arbitration on the sole issue of damages to avoid a lawsuit. …
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Blog, Medicare Advantage Part C, Pharma Part D

The Medicare Advocacy Recovery Coalition (MARC) is an organization made up of insurance companies, third party administrators, defense firms, plaintiff firms and MSP compliance companies. MARC recently announced an important new legislative initiative. Primary Plans which are plagued unfairly by MSP private cause of action claims would have an important tool at their disposal, once the legislation is introduced and …
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Part D MSP Reform Legislation Re-Introduced in Congress

20 Feb 2017 Heather Sanderson No Comments

Blog, Legal/Legislative News, Pharma Part D

On Thursday, February 16, Congressman Tim Murphy (R-PA) and Congressman Ron Kind (D-WI) re-introduced the Secondary Payer Advancement, Rationalization, and Clarification Act (SPARC Act – H.R. 1122) into the US. House of Representatives. For our prior blog and a detailed overview of the SPARC Act, click here. For Congressman Tim Murphy’s press release on the SPARC Act’s re-introduction, click here. …
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Blog, Legal/Legislative News, Medicare Jurisdiction, Medicare Secondary Payer News, Pharma Part D, Reimbursements

The Medicare Advocacy Recovery Coalition (MARC) worked diligently over the past eighteen months to develop and introduce the Secondary Payer Advancement, Rationalization and Clarification Act of 2016 (SPARC). Representatives Tim Murphy (18th District Pennsylvania, Republican) and Ron Kind (3rd District Wisconsin, Democrat) sponsored this bipartisan legislation that was immediately referred to the two committees of jurisdiction over Medicare – House …
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Blog, Franco Signor News, Legal/Legislative News, Pharma Part D

On September 24, 2016, legislation was introduced to clarify Part D Drug Plans reimbursement rights under the Medicare Secondary Payer law. The legislation will reinforce for these Plans a clear right of subrogation and improvement in Section 111 MMSEA data for improved coordination. To learn more about the proposed legislation, click here. Congratulations to the Medicare Advocacy Recovery Coalition for …
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Magistrate’s Recommendation Rejected in Humana Case

29 Sep 2014 Roy Franco No Comments

Blog, Medicare Conditional Payments, Medicare Jurisdiction, Medicare Secondary Payer News, Pharma Part D, Reimbursements, Trial Practice

This past March we wrote about the Magistrate’s recommendation to the Judge handling the Humana Insurance Co. v. Farmers Texas County Mutual Insurance Co. Cause No. 13-CV-611-LY to dismiss the claim. Our analysis of that recommendation can be found here. In brief, we compared the decision process to a boxing match that would inevitably end up in the appellate courts. …
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Blog, Pharma Part D

The Centers for Medicare & Medicaid Services (CMS) issued an important alert on August 19, 2014.  An issue of contention with the Agency by the Industry has been the pricing of prescription drugs.  Typically allocations returned with a counter higher letter by the review contractor are due to a conflict for the proposed cost of pharmaceuticals.  These discrepancies has led …
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