Health Advocates Inc. has filed suit against the Social Security Administration over procedural changes the company contends hinder its work to ensure that workers' compensation settlements are in line with Medicare requirements.
Health Advocates, based in Tampa, Fla., is a company that helps workers' comp insurers establish trusts for settlements. Under guidance from the Centers for Medicare and Medicaid Services, all workers' comp settlements totaling more than $250,000 involving workers who can be expected to become Medicare eligible within 30 months should be reviewed to ensure that Medicare does not begin paying for care until the settlement runs out, which is done through a set-aside trust.
Health Advocates performed the checks through the Tampa branch office of the Social Security Administration. The Administration maintains a database that contains, according to the suit, information about beneficiaries of Social Security programs, including the dates upon which those individual beneficiaries became or will become entitled to receive benefits under such programs.
"The process worked simply," the company said in its complaint, which was filed in a Florida federal district court. "Health Advocates would present a signed consent form from the individual beneficiary, and SSA (Social Security Administration) personnel would check the nationwide database to confirm whether the individual was presently eligible for Medicare, or could reasonably be expected to become eligible within the next 30 months."
In its complaint, the company said that it submitted roughly 500 such requests each month during the past several years, and that these requests were filled without charge.
Earlier this year, however, the SSA made procedural changes that effectively reduced the ability of companies such as Health Advocates to obtain that information. Under the new rules, the request for eligibility information is required to be made at the SSA branch office nearest the individual's home, and the Administration has also begun charging a $49 fee to fill each request.
"Despite the existence of a Medicare set-aside industry since 2001, and despite the enormous cost to the federal government of failure to protect Medicare's secondary payer status through adequate set-aside arrangements, SSA does not have a centralized or regional system for handling information requests related to Medicare set-asides and has no coherent national policy on the subject," the company said in its complaint. "Instead, each SSA field office exercises standardless discretion to honor or refuse information requests. Health Advocates' information requests have been denied repeatedly by various field offices, despite Health Advocates' submission of an official SSA request form signed by the beneficiary, and even when the requests relate solely to beneficiaries who reside in the geographic area of the relevant field office."
June Simpson, president of Health Advocates Inc., said it is "unfortunate" that the company "has been forced to file a lawsuit against the Social Security Administration to compel them to provide the information needed to reimburse Medicare for expenses that were not their responsibility, and more important, to avoid payment of future medical expenses that are not Medicare's responsibility."
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