August 17, 2023 • 50 mins
The Past, Present, and Future of Medicare Set-Asides with Rafael Gonzalez.
In this initial episode of DRI’s Comp Conversations, Ryan Hathcock of Chartwell Law, www.chartwelllaw.com, and Steve Armstrong of Armstrong and Peake PLLC, www.armstrongpeake.com speak with Rafael Gonzalez of Cattie and Gonzalez, Cattielaw.com, about Medicare secondary payer issues and compliance, including how best to consider and protect the interests of Medicare/ CMS (Centers for Medicare and Medicaid Services). Rafael discusses the history of the Medicare Secondary Payer Act, and how we got to where we are today. Most importantly, Rafael discusses coming changes in this arena with stringent fines and new rules becoming effective February 2024. You can find Rafael on LinkedIn at https://www.linkedin.com/in/rafaelgonzalezesq/ and at his website Cattielaw.com.
To learn more about DRI and the Workers' Compensation Committee vist www.DRI.org.
#DRILawyer
#DRICommunity
In this initial episode of DRI’s Comp Conversations, Ryan Hathcock of Chartwell Law, www.chartwelllaw.com, and Steve Armstrong of Armstrong and Peake PLLC, www.armstrongpeake.com speak with Rafael Gonzalez of Cattie and Gonzalez, Cattielaw.com, about Medicare secondary payer issues and compliance, including how best to consider and protect the interests of Medicare/ CMS (Centers for Medicare and Medicaid Services). Rafael discusses the history of the Medicare Secondary Payer Act, and how we got to where we are today. Most importantly, Rafael discusses coming changes in this arena with stringent fines and new rules becoming effective February 2024. You can find Rafael on LinkedIn at https://www.linkedin.com/in/rafaelgonzalezesq/ and at his website Cattielaw.com.
To learn more about DRI and the Workers' Compensation Committee vist www.DRI.org.
#DRILawyer
#DRICommunity
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:18):
Welcome to the Conversations podcast, apodcast developed through the Defense Research Institute,
where we explore the world of workerscompensation, including the personal aspects involved in
the realm of work injuries and itslitigation, as well as future trends and
every aspect in between. My nameis Ryan Hathcuck. I'm an attorney license
in the state of Georgia, andwith me is Steve Armstrong, an attorney
(00:40):
licensed in Kentucky. Steve, howare you? I'm great. It's great
to have Raphael with us today.Yep. I'm certainly excited to get this
podcast underway, and even more excitedto talk to our first guest, who
has a wealth of knowledge in anarea that is certainly important in workers compensation
litigation, but also touches the livesof many people in our country as our
(01:00):
families and all of us get older. So today we are speaking with Rafael
Gonzalez, who is a partner atthe firm of Caddy and Gonzalez. He
and his firm are experts in providinglegal opinions concerning matters related to Medicare,
secondary payer compliance and Medicare set asides. He is a man that wears many
hats, and travels the US forhis various speaking engagements and the roles he
(01:22):
holds in a number of organizations.Rafael is joining us today from Tampa,
Florida, and we are delighted tohave him for our first episode. Rafael,
how is everything going? I amdoing great, Ryan Steve, thank
you so much for having me.What an incredible honor and a great pleasure.
And congrats to both of you intoDRII for putting this together and getting
(01:44):
us started. I love it.This is some exciting stuff to be the
first. Thank you, Rafael,and we've listened to your podcast. Can
you give us a description about yourback Rihanna, your firms activities, and
your professional background. You got it. So I've always practiced here in the
(02:04):
state of Florida. Started off onthe plaintiff side and workers compensation, although
I did a lot of Social Securitydisability, a lot of Medicare and Medicaid
from the very beginning, but alwayswith a focus on workers compensation. Took
me a little while, but Ilearned that the defense side is probably where
I fitted best, at least mentallyanyway, and so I oft to work
(02:30):
to FCCI Insurance Company. I wascorporate counsel for them for a number of
years, and through all of thatearly experience, you know, the Medicare
stuff began to make some noise,and certainly in the late nineteen nineties,
and got invited to sort of studythat issue at the federal level and the
(02:51):
applicability and sort of the effect onMedicare issues on the workers' comm side of
things. And little did I knowright that in two thousand and one this
memo and CMS would be interested intying it all up and an industry was
born. So since then I've beensort of engaged and all components from A
(03:14):
to Z of everything regarding Medicare Secondarypair. Well, I remember back in
the nineties, and I started practicingin the nineteen ninety four, and in
the nineties we just fundamentally I don'trecall doing anything with CMS Medicare protecting Medicare's
interests win did it all change?And what happened so back in before and
(03:39):
certainly during that time period steven inninety four, for example, the statute
was alive in kicking the Medicare secondarypayer had come into being in nineteen eighty.
But the focus on especially that earlypart of the sequencing was all on
conditional payments, and that's really whatthe pros and the system had built itself
(04:01):
around, is recouping back any paymentsthat Medicare made, either as a result
of a worker's conclaim or an automed mal products, you know, all
of that. There was really notalk at that time of future consideration of
Medicare's interest, and it wasn't untiltwo thousand and one when that famous Patel
(04:23):
memorandum came out that really then theconversation began to shift from not just taking
Medicare's past interest reimbursement of conditional payments, but Medicare's future interest. And so
since two thousand and one, right, it started it and it grew,
(04:43):
you know, within the first fiveyears, lots of back and forth about
whether this really was something that folksneeded to be worried about, but Medicare
certainly picked it up, wrote anumber of memorandums in the yearly part of
the two thousands and early. Bysix o seven, it was a component
of things where everybody had to worryabout it in comclaims. Okay, and
(05:06):
you talked about the second Medicare beinga secondary payer, are employers, insurers,
TPAs self insurers. Are they theprimary payers or what do you call
them? That's exactly right, applicableplans or primary payers. Both of those
are terms that are used in theCode of Federal Regulations and all throughout the
(05:27):
CMS policy guidelines that they've put outover the last twenty years. And that's
essentially right. The big idea behindthat Medicare secondary payer. If there is
a primary payer that's responsible for paymentof those medicals associated with the injury related
to the claim, right, thenMedicare is a secondary payer. Those sources
(05:50):
that are primary must be spent firstbefore Medicare starts to pay. Hence,
you know that Medicare secondary payer ofname they gave it. Yeah, Sir
Raphel just taken a step back froma broader picture. For those that don't
know, can you just tell usbriefly what CMS is and how they developed
(06:11):
the Medicare Secondary payer acting, howlong that's been in existence? You got
it? So CMS stands were thecenters for Medicare and Medicaid services. That's
sort of the federal agency within theUS Department of Health and Human Services that
oversees all of these things that we'retalking about here today. The idea behind
(06:34):
the secondary payer has been around fromthe very beginning Medicare gets started in nineteen
sixty five, and even from thevery beginning Medicare was a secondary payer to
workers' compensation. Took them a while, but eventually they started to figure out
that Medicare was pain for a bunchof medical bills that they probably shouldn't have
(06:59):
been pain for in other areas ofthe law. And so in December of
nineteen eighty, Congress passed both chamberspassed, and the President signed into law.
I think it was on the lastfew days of President Jimmy Carter's presidency
that he signed into law the MedicareSecondary Payer Act. And so that's sort
(07:19):
of how we know it, ifyou will, today, and that's really
the beginning of the modern era ofMedicare secondary payers. We know it today,
got it well and learning a littlebit more about you before we jumped
on this podcast, I was toldthat you have actually testified in front of
Congress on a number of occasions.Can you tell me a little bit more
(07:40):
about that in the substance of thoseof those testimonies, sure, so,
as you can well imagine, right, the the statute itself has gone through
tremendous changes, has been amended fouror five different times here in the last
twenty years. And it is anarea it's so obscure, it's so off
(08:01):
the beaten path, it's so strange, you know, to so many folks,
especially on the hill, that theyneed a little help understanding the reasons
why and how it, you know, sort of fits in within this bigger
bullpark, if you will. I'vebeen lucky enough to have been asked a
couple of vocations to have assisted bothof the chambers and several of the members
(08:24):
and their committee individuals, members ofthe committees that needed some help and just
what in the world does it meanand why does it go like that?
So, you know, we doa lot of ryan, I do a
lot of settlements, and many ofthose settlements include Medicare seticides. Let's talk
(08:46):
about the why why do we needMedicare set asides? And are they ever
actually required by law? So you'resitting today with with all of you,
right, the answer to that questionis it is not a part of the
US Code, and there's very limitedsubsections of the Code of Federal regulations that
(09:07):
speak to this ideology of future medicals. So all throughout the user guides and
these different memorandums, if you will, that have been written over a time,
that have now been put together intothis reference guys and user guys at
CMS, the idea is still verymuch today that a Medicare set aside is
(09:28):
not required. It is still avery much a voluntary component of, if
you will, settling a file.Having said that, Medicare has said it
again and again and again that itis in their eyes, the best way
to take care of Medicare's future interests. So they highly recommend the parties engage
in an exercise where they look atthe future medical needs of that particular individual
(09:54):
priced amount over life expectancy and makeplans for funding those needs as par of
the overall settlement of the case.If the parties are settling future medical needs
related to the file, so it'sstill not required. It's certainly not required
even to submit these msays over toCMS for review. Both of those components
(10:15):
are still voluntary but highly recommended byCMS, and so does CMS. It
kind of consider the Medicare set asideto be the gold standers, so to
speak, in considering and protecting theirinterests. They do, and they spend
a lot of time, energy andresources in putting together a really comprehensive process
(10:37):
now to do that. It isstill the only area workers comp where we
have a process, a methodology tocollect all of that evidence, put together
a report and submit it to theCenter for Medicare Medicaid Services for their review,
for their analysis, and ultimately fortheir review and approval. So it
(10:58):
is, although still voluntary, verymuch right what CMS would like us to
do, and they've put together asystem where we can submit all of that
evidence and obtain from them their sortof stamp of approval, if you will.
So like you call it a goldstandard, it still very much is
because it both identifies that you've takencare of Medicare's future interest and it solidifies
(11:24):
that you've done right by them.So in essence, that's the best way
to know that. You know,you can leave this file fully knowing that
you've got Medicare's blessing as to whatyou did to resolve the issues, the
medical issues. Yeah, so Steveand I are obviously litigators, and some
of the people that will be listeningto us are also practicing attorneys, and
you know, our job is tokind of identify when a case is right
(11:48):
to prepare an essay and have onesubmitted to to CMS. But we don't
actually do any of that ourselves andkind of refer that to our clients and
they have their own internal procedures.But my understanding is that you are part
of that process. You do submitmsas to CMS. Is that correct?
We do. We do on allfifty states and on both sides of the
(12:09):
fens, So absolutely, we're usedto doing that all the time. Okay,
And just briefly, will you takeus through that procedure of how you
get an MSA and how you submitit to CMS for review. Sure?
Sure, So if there is thoughtof settlement of the future medical needs associated
with the file and that individual iseither a current Medicare beneficiary or someone who
(12:37):
is going to be a Medicare beneficiarywithin the next thirty months thirty months from
the data settlement, Medicare has highlyrecommended that you do something like a Medicare
set aside to take Medicare's future interestinto account. You guys know the process
probably as well as I do.Right, You've got to make sure you've
got at least the last two yearsworth of medical records. You have to
(13:01):
make sure you know you've got thepayouts of what that employer carrier or TPA
has paid as a result of thisclaim to be able to document to CMS,
what are the compensable injuries, whatare the things that the employer carrier
TPA maybe has paid for throughout thecourse of the file. Here, document
those medical needs and then try andprice out based on those recommendations those future
(13:26):
medical needs. Price them out byway of fee schedule to that particular state.
And that state doesn't have a feeschedule, then you can use usual
and customary to the geographic region wherethe claimant resides. And all of this
applies to both medical care as wellas prescriptions. Prescriptions of course are priced
under the average wholesale pricing per redbook instead of any usual and customary type
(13:50):
fee schedules. So that's sort ofthe standard, if you will, that
Medicare has put together. You know, when ask asking folks, how do
you take Medicare's interest to account,that's sort of the boiler plate, right,
the template they've created as far assubmitting them to CMS and getting them
looked at or approved. Because oflack of manpower, Medicare has had to
(14:13):
set some guidelines as to which ofthese things are they going to be able
to look at. So they willtake a look at cases where the individual
is a current Medicare beneficiary and thecase is settling for more than twenty five
thousand dollars. If the claimant isnot a current Medicare beneficiary but anticipated to
(14:33):
become one within the next thirty months, then they will only review msas if
the settlement is for greater than twohundred and fifty thousand dollars. So that's
you know, those are the twostandards that Medicare has given us again,
lack of manpower, lots and lotshas been written by CMAS that in all
(14:54):
workers compensation cases, Medicare's interest futureinterests should be considered, right, So
we know that they want us tolook at these situations in every case,
but they will only review these msason those very limited circumstances. Okay,
yeah, and something along the samelines but a little bit different is the
preparation of a non submit MSA.I've seen a handful of those, and
(15:16):
maybe you guys have been around alittle bit longer have seen more of those
in the past. But clients arenow a little bit more adverse to preparing
non submit msas, and they'd ratherjust go ahead and send them in.
But for those of us that stillhave clients that are willing to prepare non
submit msas, what are some thingsthat we need to think about in doing
(15:37):
so? So? First thing aboutnon submit msays, they're very much okay,
right. A lot of folks askstill that question, are they legal?
Are they permissible? Am I doingsomething wrong if I don't submit that
MSA to CMS? And the answeris you're doing just fine, right.
You're taking Medicare's future interest into consideration. There is no legal requirement to submit
(16:00):
them, So it's okay not tosubmit an MSA. Second component, you
know about that, and I thinkyou sort of integrated in your question.
It's in there is it's not anopportunity right to reduce future medical cost just
at your own will you still haveto follow these guidelines that you've got to
(16:23):
take the future medical needs of thatparticular individual into account. You've got to
be honest, if you will,about those medical records and the recommendations in
them. I will tell you thathere in twenty two, in twenty twenty
three, Medicare has gotten more andmore aggressive about these non submits, and
(16:48):
the reason is because they saw anumber of them that were abusive in nature.
Right where the MSA should have beenthirty forty fifty thousand dollars, only
five or ten were being set aside. They saw enough of those they put
out in writing a warning to theindustry, right it said, we don't
(17:08):
like them. We don't like thesenon submits because we see what you're doing
with them. I think it's sortof a bell to all of us in
the industry. You know, hey, you still have to do right by
these things. You've got to listento the evidence. You've got to pay
attention, you know, to whatthe recommendations are. So you know,
that's I think that's the biggest componentof what I would communicate to practitioners out
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there, that you don't have tosubmit them, but you still have to
be, you know, honest aboutthe evidence in front of you to be
able to allocate correctly. Raphael,there was a time a few years ago
when it seemed like it took along time to get submitted Medicare set asides
back from CMS, and it wasa factor and being able to settle the
claim because the claim it didn't wantto wait that long. But now,
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in your experience in the past yearor two, how long does it generally
take to get a medicare set asideapproved by CMS or rejected for that matter,
Steve, You're absolutely right. Youknow, in two thousand and four,
oh five, oh six, ohseven, it was not unusual for
us to have to wait a yearto hear back from CMS. It just
(18:18):
was crazy and it really drove folksnuts, you know, to have to
wait around that long for cms's approval. Fast forward today, it's a much
much different story. CMS has hiredI think this is now their third different
contractor under this worker's comp msa reviewprocess, and they just an amazing job.
(18:44):
So today it's not unusual for usto get an answer back from CMS
within thirty days. We have filesthat within fifteen days we have an approval
back, and you mentioned it.There are some cases where you will submit
them and they're reviewer comes back with, hey, you missed the boat on
this one right. There should havebeen two more MRIs or one more CT
(19:07):
scan, or ten more visits withthe ortho or the neuro and so they
will ask for a greater number ofdollars than were proposed in that MSA.
Having said that, again, theanswer normally now across the country, we
see those answers back within thirty days. It's very standard now. So what
a huge difference a decade has made. And I've had a few come in
(19:32):
higher, but not many. Haveyou ever seen any come in lower where
CMS actually said, hey, you'repotentially paying too much here I I have
right. So that's that's the Ithink the good news there is that they
are watching for right, is theremore that was needed based on the records
or did you overallocate based on certaincomponents of it? So I have seen
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some files where they will come backand say, no, you overallocated on
ortho those or neuros or medications orwhatever it may be, and the number
comes back smaller. Doesn't happen asmuch as when they want more, but
it does happen enough that we've noticedit. I've hit a few zero dollars
msas over the years, and theyactually got approved for those who don't know
(20:18):
what is a zero dollar MSA andwhen would you use it? So zero
dollar msas still very much allowed andvery much approved by CMS. Right.
It's an instrument to be able todocument that even though you are settling the
file and you are putting dollars tosettle this case on the table, that
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none of those dollars, zero dollarsout of that full settlement will be allocated
towards future medical needs that could otherwisebe argued are related to this case.
And usually you know the circumstance underwhich you would use a zero msas if
you've got a total denied workers compensationclaim. It's been denied from the get
(21:03):
go, no indemnity or medicals havebeen paid. Employer carrier feels like they've
got a pretty good defense here.The case is settling, so you want
to be able to introduce all ofthat evidence as to why the employer carrier
deny the claim to begin with andwhy they felt pretty strongly about it,
to be able to document to medicarethat you're not paying for the future medicals
(21:26):
here, and so a zero MSAwould be appropriate. Another circumstance we see
very often is where the claim mayhave been compensable at one point, but
something happened along the way, whetheran intervening accident. You know whether the
claimant really did improve and now nolonger needs further medical care related to the
claim. So something factually happen thatnow makes the future medical needs also a
(21:52):
zero, and so it would beappropriate to ask Medicare to approve a zero
again providing Medicare with all of thatevidence to prove your point there as well,
gotcha question, are there people outthere in general who you would never
have to do a Medicare set asidefor at all? To give an example,
I had a lady who had barelyworked just a few months in her
(22:17):
lifetime, and she was not goingto hit the forty quarters at all.
Now, we still need to considerprotect Medicare's interest in that kind of circumstance
if you're ever hit an experience withthat kind of claimant, Steve, that's
a great question because it trips uppractitioners all the time. Where I think
we're all used to write. Inorder to become eligible for Medicare, you
(22:41):
have to have a certain quarters ofcoverage availability. Right, You're either entitled
to Social Security disability before H sixtyfive or you're entitled to Social Security retirement
posts H sixty five. That's usuallythe entrance into Medicare. What I think
a lot of folks don't realize isthat for folks who do not meet those
(23:04):
quarters of coverage at age sixty five, there's still eligibility for Medicare. The
mountain there though, right The bigchallenge there is the premium that those individuals
will have to pay for Medicare coverageis significantly higher than those folks that did
have the quarters of quarters of earnings, if you will, just to give
(23:26):
you an example, Medicare Part A, the hospital portion of Medicare. If
you've worked and you've paid into thesystem, you know, your entire life,
you're going to pay zero premium dollarsfor hospital coverage Part A. You're
going to pay about one hundred andseventy dollars today for Medicare Part B,
(23:47):
the physician coverage, if you will, so to have hospital and physician coverage.
One hundred and seventy dollars. That'sfor an individual who's paid into the
system, who's got the quarters ofcoverage. Now let's talk about somebody who
doesn't have those quarters of coverage.At age sixty five, that individual becomes
eligible, but the premium for PartA is over two hundred and eighty dollars
(24:11):
the premium for Part B is anothertwo hundred and forty something dollars, So
altogether that individual is going to payover five hundred dollars in premiums for that
same coverage that you and I individualswho've paid into the system will pay one
seventy. So a lot of folksin that circumstance end up not signing up
(24:33):
for amb just because the finances ofthat coverage makes it impossible for them.
But to answer your original question,that does not make it that they are
not eligible. They are, they'rejust not enrolled because of the premium.
Right, A lot of state programs, in order to encourage that enrollment in
(24:55):
Medicare, will through the Medicaid system, pay the Medicare premium. So there's
lots of Medicaid programs, again,either for the elderly or for the poor
who may not have the dollars togo straight into Medicare, that Medicaid program
in the state will pay the premiumso that the Medicare coverage will be primary
(25:18):
there and that's a savings mechanism tothe Medicaid system in every state. So
I think the answer to your question, even though they may not be enough
quarters of coverage. Do not assumethat that individual is not eligible. Oftentimes
they are and it's the finances thatmay be keeping them away. Kind of
along those same lines, in certaincases you will have a pro say claim
(25:42):
it and of course you start throughthe process of litigating that file you realize
that MSA might be necessary. There'sissues that could arise with whether you get
a self administered MSA and they beginto use those funds on whatever else may
be out there, or issues relatedto when they spend those that CMS may
(26:03):
come looking back at the employer.If those funds are no longer in that
self administered fund, what is thebest way to make sure a pro say
claimant is protected from having to dealwith a lean from CMS. So that's
where I think going to CMS andgetting this MSA approved by CMS works makes
(26:25):
sense because from the employer carrier perspective, you've proven to Medicare that you took
Medicare's future interest into account, youfunded that which Medicare approved. So for
the employer carrier TPA out there,going through that process guarantees you if you
will compliance on the claimant side,the unrepresented claimant, right, I think
(26:52):
we've got to work really hard atmaking sure that that individual understands what it
is MSA is for what it's supposedto be used for, when he or
she can out or should not usethose funds. And then the ultimate bad
news is if those funds are misspent. Right, that claimant must be absolutely
aware that he or she may losecoverage. Right, that Medicare will deny
(27:18):
payment of medical bills related to thisinjury. Right, and that if Medicare
should pay in the future and thatindividual may not have the resources to pay
back, that Medicare will one way, shape form or another make an attempt
to recoup those dollars back, eitherby reducing by reducing their monthly disability benefits
(27:44):
or monthly retirement benefits, or byshipping over that file to the US Department
of Treasury and grabbing dollars from atax return if that's available. Right,
So, lots of different things thatMedicares do and today that they may not
have done five or ten years ago. They've gotten very aggressive today about making
sure that those dollars are returned backto them. Yeah, well that's interesting.
(28:10):
I had not heard of that.So it sounds like you may have
seen some of those worst case scenarioswhere per se claim it runs out of
money. But in similar situations likethat, have you ever seen CMS clawback
at the employer or the insurer orare they protected because they got that approved
MSA. Is there any way thatthat CMS can come back at the employer.
I'm sure in that scen area.So, I mean, unfortunately,
(28:32):
right, I have seen some caseswhere Medicare has gone back to original employer
carrier and try to recoup back someof those some of those payments. And
that's for example, in situations wherean MSA was not approved. Right,
in situations where for whatever reason,those original conditional payments were not paid back
(28:57):
during the settlement period of time,they were sort of left open, if
you will, right, I've alsoseen it where and we haven't spoken about
this component of Medicare secondary period,but we're through the mandatory reporting aspect of
things, that employer carrier never terminatedongoing responsibility for medical, right, they
(29:21):
settle the file, but through themandatory reporting they still said to Medicare,
we're still the responsible entity. Ourmongoing responsibility for medical still belongs to us.
So because that employer carrier technically hasassumed ongoing responsibility Medicare, then if
(29:41):
they make any payments, we'll goback to employer carrier to get reimbursement.
So I mean the lesson there isgetting that MSA approved. Absolutely and very
very important is that the mandatory reportingaspect of your claim that data that you're
providing medicare with is accurate. Ittells the correct story, It's absolutely correct
(30:03):
based on the facts of the situation. Okay, have you ever run into
a scenario where you've seen an insurercarrier be assessed with fines related to something
they've done with an nsay? Iguess in my mind, I would think
it would be applicable in a situationwhere there's clearly an MSA that's been underfunded
and somehow gotten past mustard. Buthave you ever seen a situation in which
(30:26):
finds have been assessed? So findesright and civil monetary finds as I know
them to be in the statute inthis world of ours right now are only
applicable for individuals for entities that havenot complied with that mandatory reporting right.
(30:48):
The statute says up to one thousanddollars per day per file for non compliance
of the mandatory ensure reporting aspect ofthings. We have not had any entity
that has been fined under that statutoryprovision. We do have some proposed rules
(31:10):
that have been put in play byCMS. They have now told us that
in February or before February of twentyfour, they will come out with final
rules with regard to when will SMSchase after payers for one thousand dollars per
day profile civil monetary penalty. Soeven though that law was passed back in
(31:36):
zero seven, so it's been awhile, right, we still do not
have final regulations on that. We'vebeen promised final regulations by February of twenty
four, and I believe them.I think that they are put together.
They're working on the last bed ofhere, so we're going to find out
here soon enough. I can tellyou from the rules that have and proposed
(32:00):
if they're similar to what the finalrules are going to be. They've already
told us if you are one ofthese entities and you've not registered with the
federal government, you're going to getfine a thousand dollars per day profile.
If you have been reporting data butmore than twenty percent of your data is
(32:20):
incorrect, they're going to come andget you, you know, under the
civil monetary penalties. And the lastis if the information you have provided is
inconsistent with the arguments that you're makingon the conditional payment resolution side of things,
then they're coming for civil monetary penaltiesas well. So I figured that
(32:43):
those are the three sort of staples, if you will, of the civil
monetary penalty rule. That's what's coming. We're going to get more details on
the final version of the rule,but I think that's what's coming at us
to come with February twenty twenty four. Can we come back to that in
(33:04):
just a few minutes. Can Iask you first about professional administration? It
seems to me that there's this newindustry that wasn't even there ten fifteen years
ago on professional administration, and alot of jurisdictions are requiring that now,
including mine, or they maybe notrequired, but they really really want to
see it for a claimant even who'srepresented, what is your experience with that.
(33:30):
You're absolutely right, sort of anew industry within the industry, if
you will, And it's understandable.Right, claimant now settles the file,
everybody's gone, and the claimant startsto ask what can I do with this
(33:50):
money? How much can I paythe orthopedic surgeon who's still seeing me?
How much can I pay you forthat physical therapy session? How much can
I pay for that MRI or thatCT scan or you know, whatever the
diagnostic study may be. So theinjured individual begins to, you know,
ask what exactly are the medical servicesthat I can use these dollars for and
(34:15):
exactly how much can I pay?It's hard, it is not easy to
find the answers to that. You'vegot to dig deep into the CMS bowels
of information to figure out what's medicareallowable, you know, what's related to
the claim, What would the comsystem pay for and what's the right fee
(34:37):
under that workers come fee schedule forthat particular service. So, as a
result, this industry has been bornwhere a professional administrator, you know,
would come in and would you know, sort of go down that river with
the injured worker, would assist himor her in figuring out, you know,
(34:59):
what is it that the doctor isasking for. Is that a medicare
allowable service? If it is,what would the fee schedule under the common
system be for that? And that'sthe payment that would be sent to the
doctor out of that Medicare set aside. There is also attached to that an
annual reporting to see a mass.Right, I started off with twenty thousand
(35:21):
dollars, that was my MSA.This year I spent one thousand dollars.
Here's the explanation of how those thousanddollars were spent. Means I've got nineteen
thousand left. Here you go,Medicare. Here's my annual accounting of what
I've been doing with these dollars,so that Medicare is unnoticed, that these
dollars are being spent appropriately, andby the time it is exhausted, Medicare
(35:43):
will be begin to you know,the primary payer status if you will.
Right, it makes a lot ofsense. It's helpful for the claimants to
go through that process. Yeah,and you know, the Chief Jadge here
points out that a lot of attorneyswould they'd be able to do the reporting
process, but it would take sometime and effort, and so your average
person would have a hard time reportingto the federal government. What about cost
(36:07):
If costs come down for the professionaladministrations in the past few years significantly,
right, So that if you andI were having this conversation, you know,
ten fifteen years ago, the costwas prohibitive and that really was the
reason why a lot of injured workersjust did not go professional administration route.
(36:29):
Today, the cost has dropped downsignificantly. It's very affordable now, and
so as a result, we're seeingmore and more injured individuals settling with an
MSA, you know, taking advantageof the use of a professional administrator to
help them through that. So itmakes a lot of sense, and the
(36:49):
cost associated with it now just alsomakes a lot of sense. We were
talking about earlier about preparation of theMSA. You mentioned two years of medicals,
and I think he might have touchedon prescription costs too as being in
there. I know that you've gotto look back and gather all of that
information. But in terms of whatis not accounted for, and M say,
(37:09):
can you go through maybe what kindof medical treatment is not included?
Certainly there's probably some new types ofexperimental drugs or something along those lines that's
not included in there. Can youdive into that a little bit? Absolutely,
And it's a large list of itemsthat Medicare does not cover. The
(37:30):
good news for the injured individual isthat every year more and more of these
services are covered by Medicare. Buthaving said that, you know there are
limitations as to the number of physicaltherapy visits, the numbers of orthopedic or
neurological visits that Medicare would cover ina year, And there is care and
(37:51):
treatment that Medicare either because of experimentalbasis or otherwise just would not cover.
So, for example, one wesee all the time is chirop services,
right, usually not covered by Medicare. There are a couple of exceptions here
and there, but generally not covered. So those are the type of services
that, although needed, necessary andvery much a part of the care and
(38:13):
treatment for that injured worker, thatwould not be a part of the MSA
over claiman's life expectancy. You indicatedthere are some medications right that maybe have
just come on and are not yetcovered by the Medicare system. Right.
Again, that list does continue togrow medications that are covered by Medicare,
(38:34):
but there are quite a number ofthem that aren't, and so we've always
got to be very very watchful aboutmaking sure that we're included those things that
are covered and those things that arenot. We still want to make sure
that everybody knows right. These thingsare needed, but they're not covered by
the Medicare system today. What aboutmedical marijuana? Have you seen any of
(38:55):
those try to be creeped in andwhethers have been accepted at all? I'm
assuming not even certain states have approvedit. Federal government's not quite there yet.
Is that you're understanding as well.That's you're absolutely right on that.
And we have had some clients thathave asked us put it in right,
ask Medicare for it. Medicare's answeris still very much nope. This is
(39:15):
not allowable under the federal system,so we're not going to include it in
an MSA. That may change,you know, sometime down the line,
but for today, the cost ofthat particular type of treatment is not includable
in an MSA because CMS would notapprove an MSA with that type of you
(39:37):
know, medication. If you willfor it, yeah, Raphael, we'll
do it. We'll get an MSAfrom time to time, and then something
will happen in six months, ruleby eight months, rule by we can't
get forward for some reason or another. When do you have to do when
did it become a stale and whendo you have to do a new one?
(39:57):
The rule of thumb there for Medicareis six months. Right. If
you've got an MSA that was donewithin the last six months, and you've
got medical records, you know,to support all of the things that you
put in that MSA within the lastsix months, Medicare will take a look
at that. Anything beyond six months, you know, they want a refresh.
They will allow you to submit itand once they look at it,
(40:22):
they'll come back and they'll develop thefile. They'll ask you to, hey,
will you please get us updated medicalrecords from doctor Smith or doctor Jones,
since you know what we have noware more than six months old.
So six months is the rule ofthumb there. Medicare wants to see our
records that are, you know,fresh as of the last six months.
Yeah, okay, And why dowe need to go out and get pharmacy
(40:45):
records for the past two years?I have these claimants or their attorneys sometimes
don't understand the need for that,and they say they feel like I'm prying,
and please believe me, the lastthing I want to read is somebody
else's pharmacy records. Yeah, itcontinues to be a real issue, And
you're right, that's usually the response. Right. So what Medicare is watching
(41:06):
for is what medications have been prescribedand have been paid by the employer carrier
right as compensable part of the claimto be able to figure out you know,
as the transition of the file goesthrough, you know, are there
medical records a substantiate that's no longerneeded, or the doctor is no longer
(41:28):
prescribing that that's been replaced with thisother medication, or that medication is no
longer you know, the need isno longer there because it's not providing the
relief necessary, right, And sothe doctor may be going down a different
road. That's why they want tosee those older records. They want to
figure out what has remained here,what has stopped, what has been replaced,
(41:51):
what other plants are there. Sothe combination of medical records and printed
payout from the pharmacy provides Medicare witha pretty good as to what that claimant
is now doing and may need downin the future. Another quick question,
heady, calculate the two hundred andfifty threshold payments for MSA, like,
(42:13):
do you include the past medicals alreadypaid the past indemnity or are we just
looking at the future payments in thesettlement agreement. So both the twenty five
thousand threshold and the two hundred andfifty thousand threshold, no past indemnity paid
benefits are includable in there. Nopast medical benefits paid are includable in there.
(42:35):
What we're going to throw into themix here is what are we settling
the file for, so everything futureand so we do throw in their indemnity,
we do throw in their medical wedo throw in their attorney's fees and
costs. Right, so everything that'spart of the overall global settlement that you
are working together here, that's what'sincludable in that either twenty five foul or
(43:00):
two hundred and fifty foul, youknow, depending on whether current medicare beneficiary
or soon to be within thirty months. Great, Well, as we're wrapping
up here, I want to kindof touch into what you kind of see
as the future of MSAS and CMShandling of those. You know, preparation
of MSA is all about looking forward. So in your mind, I know
(43:21):
you touched on this in terms offines that are coming down the pipe in
February twenty twenty four, is thatthe major development in terms of the world
of msas or what do you seeas the largest aspect coming our way?
So, right, I think Iwant to teach our industry to start talking
about Medicare Secondary payer instead of Medicareset aside. Right, And here's the
(43:45):
reason why Medicare Secondary pair is sortof the big ball of wax. Here
inside Medicare Secondary pair are three componentsthat we all need to be concerned about.
One is mandatory reporting that thousand dollarsper day per file. Right,
we need to make sure that thedata that we're communicating over to CMS is
(44:07):
accurate and it's timely, otherwise it'sgoing to get us into a lot of
trouble. Second thing that's part ofthat Medicare Secondary payer big ball here is
conditional payments the leans right, makingsure that as we walk away from this
case, we have reimbursed all ofthose conditional payments that Medicare has made throughout
(44:30):
the course of the file. Now, Medicare has gotten really really aggressive about
that. As of about five sixyears ago, they brought on a contractor
just to chase after employer carriers andTPAs and comp cases, not waiting around
until settlement. So if Medicare makesa payment today, Medicare has a record
(44:51):
of it. Then they give itto this new contractor, the Commercial Repayment
Center, and that CRC, theCommercial Repayment Center contract actor, chases after
that employer or carrier for reimbursement ofthat conditional payment. So that process is
new and it's aggressive. Right.This last report from the CRC shows that
(45:13):
over the last since twenty fourteen,they've recouped back over a million, over
a billion dollars right to the MedicareTrust Fund from workers comp cases alone.
So getting really, really aggressive onconditional payments. I think I already indicated
they're using the US Treasury, They'reusing the US Department of Justice to go
(45:34):
sue folks that haven't reimbursed conditional payments. So it's real, it's aggressive,
it's happening. So mandator reporting becauseof the obvious reasons, right, a
thousand dollars per day profile civil monetarypenalty and these conditional payments. And when
I say conditional payments, most ofus thinking ten, fifteen, twenty years
(45:55):
ago, we were only blindfolds onthinking about traditional Medicare. Today, over
fifty percent of all Medicare beneficiaries aregetting their Medicare coverage through a Medicare advantage
plan. Humanis United's sickness edness ofthe world. Right, if we do
(46:19):
not have a plan in place tonot only touch base with the traditional Medicare
system, but with these private plansthat are providing the Medicare coverage, that
we're missing half the battle here,Right, So you and I could settle
a file, nothing owe to Medicare. We're thinking, touchdown, we win.
Right. A year or two later, here comes Humana, Here comes
(46:42):
United, Here comes that Medicare advantageplan saying, hey, you settled it
two years ago, you never askedus, You owe me twenty thousand bucks.
I'm here to collect. Those entitieshave the same rights as the traditional
Medicare system to engage recoup and ifnot, to file suit for double damages.
(47:02):
Right. So, that mandatory reportingand the conditional payment side of things
is where I think I want theindustry to make sure you focus on that
Medicare set aside. You know,we've learned a great deal about it.
It is still a voluntary system.The things that are must absolutely mandatory is
(47:22):
that we report the file and thatwe reimburse conditional payments. So before we
talk about an MSA, let's talkabout reporting. Let's talk about conditional payments.
Because I think as an industry we'velearned really well and really are doing
a good job on this MSA stuff. It's these other two buckets that I
want to make sure industry is startingto learn a little more about and starting
(47:46):
to get more serious about. Yeah, well, I know that I have
clients ask about mssas all the time, and it's still an area that people
just really really struggle with because there'sso many different nuances to it. And
to see now that we've got thesepenalties coming, that's even more troublesome.
And I know our clients will probablykind of wake up to that. So
it'll be on us to kind ofget that word out to our clients to
(48:07):
make sure that they're on top ofall this. But I want to thank
you so much for taking the timetoday to come speak with us and sharing
all of your knowledge. I knowwe could probably continue down this road for
an hour or so, but it'sbeen a pleasure having you on it.
This is my first time getting tospeak with you about this, so I
know that I've learned a lot.But and you're a busy man. We're
(48:27):
two next for you. I'm headedoff to Florida RIMS here in a week
or so and then to SOCCA SouthernAssociation of Workers comp Administrators speak at that
conference as well. So July isis still busy as I'll get out.
And of course we've got WCI rightaround the corner here in August. I'm
(48:49):
looking forward to that as well.Great. Well, what's the easiest way
for our listeners to get in touchwith you if they want to learn more
about you or reach out to youand your services with Kaddy and Gonzalez.
Our website at ww Kaddy Gonzalez alwaysa good source and you can find our
email addresses and phone numbers and allof that there, so and of course
it's full of information. You're morethan welcome. I blog a bunch about
(49:13):
all of these issues and those areall published up there, and we try
to provide the industry with you know, that knowledge, the case law,
you know, the statutory stuff that'shappening all the time, so as to
be able to make sure that ourindustry stays up and what's going on in
all of this. And there arethere other ways to connect with you.
Social media. Yeah there is that, isn't there right, it's for an
(49:35):
old guy like me to I don'tknow how in the world this stuff with
the ralphies, you know, happened, but what an incredible thing. One
hundred thousand followers later, here weare living in social media and putting it
out and about every single day.So it's incredible for an old guy like
me. You know, this iswhat a world if for our listeners that
(49:59):
don't know. Ralphie is a Rafaelselfie and has become quite the spectacle on
LinkedIn. So too if you're tuneif you're tuning in and make sure you
go connect with him. He's gotplenty of content to share and as always,
has a ton of information. SoRafael, thank you again for your
time today. Thank you, Rafael. Thank you guys so much. What
a great honor. Thank you
Welcome to the Conversations podcast, apodcast developed through the Defense Research Institute,
where we explore the world of workerscompensation, including the personal aspects involved in
the realm of work injuries and itslitigation, as well as future trends and
every aspect in between. My nameis Ryan Hathcuck. I'm an attorney license
in the state of Georgia, andwith me is Steve Armstrong, an attorney
(00:40):
licensed in Kentucky. Steve, howare you? I'm great. It's great
to have Raphael with us today.Yep. I'm certainly excited to get this
podcast underway, and even more excitedto talk to our first guest, who
has a wealth of knowledge in anarea that is certainly important in workers compensation
litigation, but also touches the livesof many people in our country as our
(01:00):
families and all of us get older. So today we are speaking with Rafael
Gonzalez, who is a partner atthe firm of Caddy and Gonzalez. He
and his firm are experts in providinglegal opinions concerning matters related to Medicare,
secondary payer compliance and Medicare set asides. He is a man that wears many
hats, and travels the US forhis various speaking engagements and the roles he
(01:22):
holds in a number of organizations.Rafael is joining us today from Tampa,
Florida, and we are delighted tohave him for our first episode. Rafael,
how is everything going? I amdoing great, Ryan Steve, thank
you so much for having me.What an incredible honor and a great pleasure.
And congrats to both of you intoDRII for putting this together and getting
(01:44):
us started. I love it.This is some exciting stuff to be the
first. Thank you, Rafael,and we've listened to your podcast. Can
you give us a description about yourback Rihanna, your firms activities, and
your professional background. You got it. So I've always practiced here in the
(02:04):
state of Florida. Started off onthe plaintiff side and workers compensation, although
I did a lot of Social Securitydisability, a lot of Medicare and Medicaid
from the very beginning, but alwayswith a focus on workers compensation. Took
me a little while, but Ilearned that the defense side is probably where
I fitted best, at least mentallyanyway, and so I oft to work
(02:30):
to FCCI Insurance Company. I wascorporate counsel for them for a number of
years, and through all of thatearly experience, you know, the Medicare
stuff began to make some noise,and certainly in the late nineteen nineties,
and got invited to sort of studythat issue at the federal level and the
(02:51):
applicability and sort of the effect onMedicare issues on the workers' comm side of
things. And little did I knowright that in two thousand and one this
memo and CMS would be interested intying it all up and an industry was
born. So since then I've beensort of engaged and all components from A
(03:14):
to Z of everything regarding Medicare Secondarypair. Well, I remember back in
the nineties, and I started practicingin the nineteen ninety four, and in
the nineties we just fundamentally I don'trecall doing anything with CMS Medicare protecting Medicare's
interests win did it all change?And what happened so back in before and
(03:39):
certainly during that time period steven inninety four, for example, the statute
was alive in kicking the Medicare secondarypayer had come into being in nineteen eighty.
But the focus on especially that earlypart of the sequencing was all on
conditional payments, and that's really whatthe pros and the system had built itself
(04:01):
around, is recouping back any paymentsthat Medicare made, either as a result
of a worker's conclaim or an automed mal products, you know, all
of that. There was really notalk at that time of future consideration of
Medicare's interest, and it wasn't untiltwo thousand and one when that famous Patel
(04:23):
memorandum came out that really then theconversation began to shift from not just taking
Medicare's past interest reimbursement of conditional payments, but Medicare's future interest. And so
since two thousand and one, right, it started it and it grew,
(04:43):
you know, within the first fiveyears, lots of back and forth about
whether this really was something that folksneeded to be worried about, but Medicare
certainly picked it up, wrote anumber of memorandums in the yearly part of
the two thousands and early. Bysix o seven, it was a component
of things where everybody had to worryabout it in comclaims. Okay, and
(05:06):
you talked about the second Medicare beinga secondary payer, are employers, insurers,
TPAs self insurers. Are they theprimary payers or what do you call
them? That's exactly right, applicableplans or primary payers. Both of those
are terms that are used in theCode of Federal Regulations and all throughout the
(05:27):
CMS policy guidelines that they've put outover the last twenty years. And that's
essentially right. The big idea behindthat Medicare secondary payer. If there is
a primary payer that's responsible for paymentof those medicals associated with the injury related
to the claim, right, thenMedicare is a secondary payer. Those sources
(05:50):
that are primary must be spent firstbefore Medicare starts to pay. Hence,
you know that Medicare secondary payer ofname they gave it. Yeah, Sir
Raphel just taken a step back froma broader picture. For those that don't
know, can you just tell usbriefly what CMS is and how they developed
(06:11):
the Medicare Secondary payer acting, howlong that's been in existence? You got
it? So CMS stands were thecenters for Medicare and Medicaid services. That's
sort of the federal agency within theUS Department of Health and Human Services that
oversees all of these things that we'retalking about here today. The idea behind
(06:34):
the secondary payer has been around fromthe very beginning Medicare gets started in nineteen
sixty five, and even from thevery beginning Medicare was a secondary payer to
workers' compensation. Took them a while, but eventually they started to figure out
that Medicare was pain for a bunchof medical bills that they probably shouldn't have
(06:59):
been pain for in other areas ofthe law. And so in December of
nineteen eighty, Congress passed both chamberspassed, and the President signed into law.
I think it was on the lastfew days of President Jimmy Carter's presidency
that he signed into law the MedicareSecondary Payer Act. And so that's sort
(07:19):
of how we know it, ifyou will, today, and that's really
the beginning of the modern era ofMedicare secondary payers. We know it today,
got it well and learning a littlebit more about you before we jumped
on this podcast, I was toldthat you have actually testified in front of
Congress on a number of occasions.Can you tell me a little bit more
(07:40):
about that in the substance of thoseof those testimonies, sure, so,
as you can well imagine, right, the the statute itself has gone through
tremendous changes, has been amended fouror five different times here in the last
twenty years. And it is anarea it's so obscure, it's so off
(08:01):
the beaten path, it's so strange, you know, to so many folks,
especially on the hill, that theyneed a little help understanding the reasons
why and how it, you know, sort of fits in within this bigger
bullpark, if you will. I'vebeen lucky enough to have been asked a
couple of vocations to have assisted bothof the chambers and several of the members
(08:24):
and their committee individuals, members ofthe committees that needed some help and just
what in the world does it meanand why does it go like that?
So, you know, we doa lot of ryan, I do a
lot of settlements, and many ofthose settlements include Medicare seticides. Let's talk
(08:46):
about the why why do we needMedicare set asides? And are they ever
actually required by law? So you'resitting today with with all of you,
right, the answer to that questionis it is not a part of the
US Code, and there's very limitedsubsections of the Code of Federal regulations that
(09:07):
speak to this ideology of future medicals. So all throughout the user guides and
these different memorandums, if you will, that have been written over a time,
that have now been put together intothis reference guys and user guys at
CMS, the idea is still verymuch today that a Medicare set aside is
(09:28):
not required. It is still avery much a voluntary component of, if
you will, settling a file.Having said that, Medicare has said it
again and again and again that itis in their eyes, the best way
to take care of Medicare's future interests. So they highly recommend the parties engage
in an exercise where they look atthe future medical needs of that particular individual
(09:54):
priced amount over life expectancy and makeplans for funding those needs as par of
the overall settlement of the case.If the parties are settling future medical needs
related to the file, so it'sstill not required. It's certainly not required
even to submit these msays over toCMS for review. Both of those components
(10:15):
are still voluntary but highly recommended byCMS, and so does CMS. It
kind of consider the Medicare set asideto be the gold standers, so to
speak, in considering and protecting theirinterests. They do, and they spend
a lot of time, energy andresources in putting together a really comprehensive process
(10:37):
now to do that. It isstill the only area workers comp where we
have a process, a methodology tocollect all of that evidence, put together
a report and submit it to theCenter for Medicare Medicaid Services for their review,
for their analysis, and ultimately fortheir review and approval. So it
(10:58):
is, although still voluntary, verymuch right what CMS would like us to
do, and they've put together asystem where we can submit all of that
evidence and obtain from them their sortof stamp of approval, if you will.
So like you call it a goldstandard, it still very much is
because it both identifies that you've takencare of Medicare's future interest and it solidifies
(11:24):
that you've done right by them.So in essence, that's the best way
to know that. You know,you can leave this file fully knowing that
you've got Medicare's blessing as to whatyou did to resolve the issues, the
medical issues. Yeah, so Steveand I are obviously litigators, and some
of the people that will be listeningto us are also practicing attorneys, and
you know, our job is tokind of identify when a case is right
(11:48):
to prepare an essay and have onesubmitted to to CMS. But we don't
actually do any of that ourselves andkind of refer that to our clients and
they have their own internal procedures.But my understanding is that you are part
of that process. You do submitmsas to CMS. Is that correct?
We do. We do on allfifty states and on both sides of the
(12:09):
fens, So absolutely, we're usedto doing that all the time. Okay,
And just briefly, will you takeus through that procedure of how you
get an MSA and how you submitit to CMS for review. Sure?
Sure, So if there is thoughtof settlement of the future medical needs associated
with the file and that individual iseither a current Medicare beneficiary or someone who
(12:37):
is going to be a Medicare beneficiarywithin the next thirty months thirty months from
the data settlement, Medicare has highlyrecommended that you do something like a Medicare
set aside to take Medicare's future interestinto account. You guys know the process
probably as well as I do.Right, You've got to make sure you've
got at least the last two yearsworth of medical records. You have to
(13:01):
make sure you know you've got thepayouts of what that employer carrier or TPA
has paid as a result of thisclaim to be able to document to CMS,
what are the compensable injuries, whatare the things that the employer carrier
TPA maybe has paid for throughout thecourse of the file. Here, document
those medical needs and then try andprice out based on those recommendations those future
(13:26):
medical needs. Price them out byway of fee schedule to that particular state.
And that state doesn't have a feeschedule, then you can use usual
and customary to the geographic region wherethe claimant resides. And all of this
applies to both medical care as wellas prescriptions. Prescriptions of course are priced
under the average wholesale pricing per redbook instead of any usual and customary type
(13:50):
fee schedules. So that's sort ofthe standard, if you will, that
Medicare has put together. You know, when ask asking folks, how do
you take Medicare's interest to account,that's sort of the boiler plate, right,
the template they've created as far assubmitting them to CMS and getting them
looked at or approved. Because oflack of manpower, Medicare has had to
(14:13):
set some guidelines as to which ofthese things are they going to be able
to look at. So they willtake a look at cases where the individual
is a current Medicare beneficiary and thecase is settling for more than twenty five
thousand dollars. If the claimant isnot a current Medicare beneficiary but anticipated to
(14:33):
become one within the next thirty months, then they will only review msas if
the settlement is for greater than twohundred and fifty thousand dollars. So that's
you know, those are the twostandards that Medicare has given us again,
lack of manpower, lots and lotshas been written by CMAS that in all
(14:54):
workers compensation cases, Medicare's interest futureinterests should be considered, right, So
we know that they want us tolook at these situations in every case,
but they will only review these msason those very limited circumstances. Okay,
yeah, and something along the samelines but a little bit different is the
preparation of a non submit MSA.I've seen a handful of those, and
(15:16):
maybe you guys have been around alittle bit longer have seen more of those
in the past. But clients arenow a little bit more adverse to preparing
non submit msas, and they'd ratherjust go ahead and send them in.
But for those of us that stillhave clients that are willing to prepare non
submit msas, what are some thingsthat we need to think about in doing
(15:37):
so? So? First thing aboutnon submit msays, they're very much okay,
right. A lot of folks askstill that question, are they legal?
Are they permissible? Am I doingsomething wrong if I don't submit that
MSA to CMS? And the answeris you're doing just fine, right.
You're taking Medicare's future interest into consideration. There is no legal requirement to submit
(16:00):
them, So it's okay not tosubmit an MSA. Second component, you
know about that, and I thinkyou sort of integrated in your question.
It's in there is it's not anopportunity right to reduce future medical cost just
at your own will you still haveto follow these guidelines that you've got to
(16:23):
take the future medical needs of thatparticular individual into account. You've got to
be honest, if you will,about those medical records and the recommendations in
them. I will tell you thathere in twenty two, in twenty twenty
three, Medicare has gotten more andmore aggressive about these non submits, and
(16:48):
the reason is because they saw anumber of them that were abusive in nature.
Right where the MSA should have beenthirty forty fifty thousand dollars, only
five or ten were being set aside. They saw enough of those they put
out in writing a warning to theindustry, right it said, we don't
(17:08):
like them. We don't like thesenon submits because we see what you're doing
with them. I think it's sortof a bell to all of us in
the industry. You know, hey, you still have to do right by
these things. You've got to listento the evidence. You've got to pay
attention, you know, to whatthe recommendations are. So you know,
that's I think that's the biggest componentof what I would communicate to practitioners out
(17:33):
there, that you don't have tosubmit them, but you still have to
be, you know, honest aboutthe evidence in front of you to be
able to allocate correctly. Raphael,there was a time a few years ago
when it seemed like it took along time to get submitted Medicare set asides
back from CMS, and it wasa factor and being able to settle the
claim because the claim it didn't wantto wait that long. But now,
(17:56):
in your experience in the past yearor two, how long does it generally
take to get a medicare set asideapproved by CMS or rejected for that matter,
Steve, You're absolutely right. Youknow, in two thousand and four,
oh five, oh six, ohseven, it was not unusual for
us to have to wait a yearto hear back from CMS. It just
(18:18):
was crazy and it really drove folksnuts, you know, to have to
wait around that long for cms's approval. Fast forward today, it's a much
much different story. CMS has hiredI think this is now their third different
contractor under this worker's comp msa reviewprocess, and they just an amazing job.
(18:44):
So today it's not unusual for usto get an answer back from CMS
within thirty days. We have filesthat within fifteen days we have an approval
back, and you mentioned it.There are some cases where you will submit
them and they're reviewer comes back with, hey, you missed the boat on
this one right. There should havebeen two more MRIs or one more CT
(19:07):
scan, or ten more visits withthe ortho or the neuro and so they
will ask for a greater number ofdollars than were proposed in that MSA.
Having said that, again, theanswer normally now across the country, we
see those answers back within thirty days. It's very standard now. So what
a huge difference a decade has made. And I've had a few come in
(19:32):
higher, but not many. Haveyou ever seen any come in lower where
CMS actually said, hey, you'repotentially paying too much here I I have
right. So that's that's the Ithink the good news there is that they
are watching for right, is theremore that was needed based on the records
or did you overallocate based on certaincomponents of it? So I have seen
(19:53):
some files where they will come backand say, no, you overallocated on
ortho those or neuros or medications orwhatever it may be, and the number
comes back smaller. Doesn't happen asmuch as when they want more, but
it does happen enough that we've noticedit. I've hit a few zero dollars
msas over the years, and theyactually got approved for those who don't know
(20:18):
what is a zero dollar MSA andwhen would you use it? So zero
dollar msas still very much allowed andvery much approved by CMS. Right.
It's an instrument to be able todocument that even though you are settling the
file and you are putting dollars tosettle this case on the table, that
(20:41):
none of those dollars, zero dollarsout of that full settlement will be allocated
towards future medical needs that could otherwisebe argued are related to this case.
And usually you know the circumstance underwhich you would use a zero msas if
you've got a total denied workers compensationclaim. It's been denied from the get
(21:03):
go, no indemnity or medicals havebeen paid. Employer carrier feels like they've
got a pretty good defense here.The case is settling, so you want
to be able to introduce all ofthat evidence as to why the employer carrier
deny the claim to begin with andwhy they felt pretty strongly about it,
to be able to document to medicarethat you're not paying for the future medicals
(21:26):
here, and so a zero MSAwould be appropriate. Another circumstance we see
very often is where the claim mayhave been compensable at one point, but
something happened along the way, whetheran intervening accident. You know whether the
claimant really did improve and now nolonger needs further medical care related to the
claim. So something factually happen thatnow makes the future medical needs also a
(21:52):
zero, and so it would beappropriate to ask Medicare to approve a zero
again providing Medicare with all of thatevidence to prove your point there as well,
gotcha question, are there people outthere in general who you would never
have to do a Medicare set asidefor at all? To give an example,
I had a lady who had barelyworked just a few months in her
(22:17):
lifetime, and she was not goingto hit the forty quarters at all.
Now, we still need to considerprotect Medicare's interest in that kind of circumstance
if you're ever hit an experience withthat kind of claimant, Steve, that's
a great question because it trips uppractitioners all the time. Where I think
we're all used to write. Inorder to become eligible for Medicare, you
(22:41):
have to have a certain quarters ofcoverage availability. Right, You're either entitled
to Social Security disability before H sixtyfive or you're entitled to Social Security retirement
posts H sixty five. That's usuallythe entrance into Medicare. What I think
a lot of folks don't realize isthat for folks who do not meet those
(23:04):
quarters of coverage at age sixty five, there's still eligibility for Medicare. The
mountain there though, right The bigchallenge there is the premium that those individuals
will have to pay for Medicare coverageis significantly higher than those folks that did
have the quarters of quarters of earnings, if you will, just to give
(23:26):
you an example, Medicare Part A, the hospital portion of Medicare. If
you've worked and you've paid into thesystem, you know, your entire life,
you're going to pay zero premium dollarsfor hospital coverage Part A. You're
going to pay about one hundred andseventy dollars today for Medicare Part B,
(23:47):
the physician coverage, if you will, so to have hospital and physician coverage.
One hundred and seventy dollars. That'sfor an individual who's paid into the
system, who's got the quarters ofcoverage. Now let's talk about somebody who
doesn't have those quarters of coverage.At age sixty five, that individual becomes
eligible, but the premium for PartA is over two hundred and eighty dollars
(24:11):
the premium for Part B is anothertwo hundred and forty something dollars, So
altogether that individual is going to payover five hundred dollars in premiums for that
same coverage that you and I individualswho've paid into the system will pay one
seventy. So a lot of folksin that circumstance end up not signing up
(24:33):
for amb just because the finances ofthat coverage makes it impossible for them.
But to answer your original question,that does not make it that they are
not eligible. They are, they'rejust not enrolled because of the premium.
Right, A lot of state programs, in order to encourage that enrollment in
(24:55):
Medicare, will through the Medicaid system, pay the Medicare premium. So there's
lots of Medicaid programs, again,either for the elderly or for the poor
who may not have the dollars togo straight into Medicare, that Medicaid program
in the state will pay the premiumso that the Medicare coverage will be primary
(25:18):
there and that's a savings mechanism tothe Medicaid system in every state. So
I think the answer to your question, even though they may not be enough
quarters of coverage. Do not assumethat that individual is not eligible. Oftentimes
they are and it's the finances thatmay be keeping them away. Kind of
along those same lines, in certaincases you will have a pro say claim
(25:42):
it and of course you start throughthe process of litigating that file you realize
that MSA might be necessary. There'sissues that could arise with whether you get
a self administered MSA and they beginto use those funds on whatever else may
be out there, or issues relatedto when they spend those that CMS may
(26:03):
come looking back at the employer.If those funds are no longer in that
self administered fund, what is thebest way to make sure a pro say
claimant is protected from having to dealwith a lean from CMS. So that's
where I think going to CMS andgetting this MSA approved by CMS works makes
(26:25):
sense because from the employer carrier perspective, you've proven to Medicare that you took
Medicare's future interest into account, youfunded that which Medicare approved. So for
the employer carrier TPA out there,going through that process guarantees you if you
will compliance on the claimant side,the unrepresented claimant, right, I think
(26:52):
we've got to work really hard atmaking sure that that individual understands what it
is MSA is for what it's supposedto be used for, when he or
she can out or should not usethose funds. And then the ultimate bad
news is if those funds are misspent. Right, that claimant must be absolutely
aware that he or she may losecoverage. Right, that Medicare will deny
(27:18):
payment of medical bills related to thisinjury. Right, and that if Medicare
should pay in the future and thatindividual may not have the resources to pay
back, that Medicare will one way, shape form or another make an attempt
to recoup those dollars back, eitherby reducing by reducing their monthly disability benefits
(27:44):
or monthly retirement benefits, or byshipping over that file to the US Department
of Treasury and grabbing dollars from atax return if that's available. Right,
So, lots of different things thatMedicares do and today that they may not
have done five or ten years ago. They've gotten very aggressive today about making
sure that those dollars are returned backto them. Yeah, well that's interesting.
(28:10):
I had not heard of that.So it sounds like you may have
seen some of those worst case scenarioswhere per se claim it runs out of
money. But in similar situations likethat, have you ever seen CMS clawback
at the employer or the insurer orare they protected because they got that approved
MSA. Is there any way thatthat CMS can come back at the employer.
I'm sure in that scen area.So, I mean, unfortunately,
(28:32):
right, I have seen some caseswhere Medicare has gone back to original employer
carrier and try to recoup back someof those some of those payments. And
that's for example, in situations wherean MSA was not approved. Right,
in situations where for whatever reason,those original conditional payments were not paid back
(28:57):
during the settlement period of time,they were sort of left open, if
you will, right, I've alsoseen it where and we haven't spoken about
this component of Medicare secondary period,but we're through the mandatory reporting aspect of
things, that employer carrier never terminatedongoing responsibility for medical, right, they
(29:21):
settle the file, but through themandatory reporting they still said to Medicare,
we're still the responsible entity. Ourmongoing responsibility for medical still belongs to us.
So because that employer carrier technically hasassumed ongoing responsibility Medicare, then if
(29:41):
they make any payments, we'll goback to employer carrier to get reimbursement.
So I mean the lesson there isgetting that MSA approved. Absolutely and very
very important is that the mandatory reportingaspect of your claim that data that you're
providing medicare with is accurate. Ittells the correct story, It's absolutely correct
(30:03):
based on the facts of the situation. Okay, have you ever run into
a scenario where you've seen an insurercarrier be assessed with fines related to something
they've done with an nsay? Iguess in my mind, I would think
it would be applicable in a situationwhere there's clearly an MSA that's been underfunded
and somehow gotten past mustard. Buthave you ever seen a situation in which
(30:26):
finds have been assessed? So findesright and civil monetary finds as I know
them to be in the statute inthis world of ours right now are only
applicable for individuals for entities that havenot complied with that mandatory reporting right.
(30:48):
The statute says up to one thousanddollars per day per file for non compliance
of the mandatory ensure reporting aspect ofthings. We have not had any entity
that has been fined under that statutoryprovision. We do have some proposed rules
(31:10):
that have been put in play byCMS. They have now told us that
in February or before February of twentyfour, they will come out with final
rules with regard to when will SMSchase after payers for one thousand dollars per
day profile civil monetary penalty. Soeven though that law was passed back in
(31:36):
zero seven, so it's been awhile, right, we still do not
have final regulations on that. We'vebeen promised final regulations by February of twenty
four, and I believe them.I think that they are put together.
They're working on the last bed ofhere, so we're going to find out
here soon enough. I can tellyou from the rules that have and proposed
(32:00):
if they're similar to what the finalrules are going to be. They've already
told us if you are one ofthese entities and you've not registered with the
federal government, you're going to getfine a thousand dollars per day profile.
If you have been reporting data butmore than twenty percent of your data is
(32:20):
incorrect, they're going to come andget you, you know, under the
civil monetary penalties. And the lastis if the information you have provided is
inconsistent with the arguments that you're makingon the conditional payment resolution side of things,
then they're coming for civil monetary penaltiesas well. So I figured that
(32:43):
those are the three sort of staples, if you will, of the civil
monetary penalty rule. That's what's coming. We're going to get more details on
the final version of the rule,but I think that's what's coming at us
to come with February twenty twenty four. Can we come back to that in
(33:04):
just a few minutes. Can Iask you first about professional administration? It
seems to me that there's this newindustry that wasn't even there ten fifteen years
ago on professional administration, and alot of jurisdictions are requiring that now,
including mine, or they maybe notrequired, but they really really want to
see it for a claimant even who'srepresented, what is your experience with that.
(33:30):
You're absolutely right, sort of anew industry within the industry, if
you will, And it's understandable.Right, claimant now settles the file,
everybody's gone, and the claimant startsto ask what can I do with this
(33:50):
money? How much can I paythe orthopedic surgeon who's still seeing me?
How much can I pay you forthat physical therapy session? How much can
I pay for that MRI or thatCT scan or you know, whatever the
diagnostic study may be. So theinjured individual begins to, you know,
ask what exactly are the medical servicesthat I can use these dollars for and
(34:15):
exactly how much can I pay?It's hard, it is not easy to
find the answers to that. You'vegot to dig deep into the CMS bowels
of information to figure out what's medicareallowable, you know, what's related to
the claim, What would the comsystem pay for and what's the right fee
(34:37):
under that workers come fee schedule forthat particular service. So, as a
result, this industry has been bornwhere a professional administrator, you know,
would come in and would you know, sort of go down that river with
the injured worker, would assist himor her in figuring out, you know,
(34:59):
what is it that the doctor isasking for. Is that a medicare
allowable service? If it is,what would the fee schedule under the common
system be for that? And that'sthe payment that would be sent to the
doctor out of that Medicare set aside. There is also attached to that an
annual reporting to see a mass.Right, I started off with twenty thousand
(35:21):
dollars, that was my MSA.This year I spent one thousand dollars.
Here's the explanation of how those thousanddollars were spent. Means I've got nineteen
thousand left. Here you go,Medicare. Here's my annual accounting of what
I've been doing with these dollars,so that Medicare is unnoticed, that these
dollars are being spent appropriately, andby the time it is exhausted, Medicare
(35:43):
will be begin to you know,the primary payer status if you will.
Right, it makes a lot ofsense. It's helpful for the claimants to
go through that process. Yeah,and you know, the Chief Jadge here
points out that a lot of attorneyswould they'd be able to do the reporting
process, but it would take sometime and effort, and so your average
person would have a hard time reportingto the federal government. What about cost
(36:07):
If costs come down for the professionaladministrations in the past few years significantly,
right, So that if you andI were having this conversation, you know,
ten fifteen years ago, the costwas prohibitive and that really was the
reason why a lot of injured workersjust did not go professional administration route.
(36:29):
Today, the cost has dropped downsignificantly. It's very affordable now, and
so as a result, we're seeingmore and more injured individuals settling with an
MSA, you know, taking advantageof the use of a professional administrator to
help them through that. So itmakes a lot of sense, and the
(36:49):
cost associated with it now just alsomakes a lot of sense. We were
talking about earlier about preparation of theMSA. You mentioned two years of medicals,
and I think he might have touchedon prescription costs too as being in
there. I know that you've gotto look back and gather all of that
information. But in terms of whatis not accounted for, and M say,
(37:09):
can you go through maybe what kindof medical treatment is not included?
Certainly there's probably some new types ofexperimental drugs or something along those lines that's
not included in there. Can youdive into that a little bit? Absolutely,
And it's a large list of itemsthat Medicare does not cover. The
(37:30):
good news for the injured individual isthat every year more and more of these
services are covered by Medicare. Buthaving said that, you know there are
limitations as to the number of physicaltherapy visits, the numbers of orthopedic or
neurological visits that Medicare would cover ina year, And there is care and
(37:51):
treatment that Medicare either because of experimentalbasis or otherwise just would not cover.
So, for example, one wesee all the time is chirop services,
right, usually not covered by Medicare. There are a couple of exceptions here
and there, but generally not covered. So those are the type of services
that, although needed, necessary andvery much a part of the care and
(38:13):
treatment for that injured worker, thatwould not be a part of the MSA
over claiman's life expectancy. You indicatedthere are some medications right that maybe have
just come on and are not yetcovered by the Medicare system. Right.
Again, that list does continue togrow medications that are covered by Medicare,
(38:34):
but there are quite a number ofthem that aren't, and so we've always
got to be very very watchful aboutmaking sure that we're included those things that
are covered and those things that arenot. We still want to make sure
that everybody knows right. These thingsare needed, but they're not covered by
the Medicare system today. What aboutmedical marijuana? Have you seen any of
(38:55):
those try to be creeped in andwhethers have been accepted at all? I'm
assuming not even certain states have approvedit. Federal government's not quite there yet.
Is that you're understanding as well.That's you're absolutely right on that.
And we have had some clients thathave asked us put it in right,
ask Medicare for it. Medicare's answeris still very much nope. This is
(39:15):
not allowable under the federal system,so we're not going to include it in
an MSA. That may change,you know, sometime down the line,
but for today, the cost ofthat particular type of treatment is not includable
in an MSA because CMS would notapprove an MSA with that type of you
(39:37):
know, medication. If you willfor it, yeah, Raphael, we'll
do it. We'll get an MSAfrom time to time, and then something
will happen in six months, ruleby eight months, rule by we can't
get forward for some reason or another. When do you have to do when
did it become a stale and whendo you have to do a new one?
(39:57):
The rule of thumb there for Medicareis six months. Right. If
you've got an MSA that was donewithin the last six months, and you've
got medical records, you know,to support all of the things that you
put in that MSA within the lastsix months, Medicare will take a look
at that. Anything beyond six months, you know, they want a refresh.
They will allow you to submit itand once they look at it,
(40:22):
they'll come back and they'll develop thefile. They'll ask you to, hey,
will you please get us updated medicalrecords from doctor Smith or doctor Jones,
since you know what we have noware more than six months old.
So six months is the rule ofthumb there. Medicare wants to see our
records that are, you know,fresh as of the last six months.
Yeah, okay, And why dowe need to go out and get pharmacy
(40:45):
records for the past two years?I have these claimants or their attorneys sometimes
don't understand the need for that,and they say they feel like I'm prying,
and please believe me, the lastthing I want to read is somebody
else's pharmacy records. Yeah, itcontinues to be a real issue, And
you're right, that's usually the response. Right. So what Medicare is watching
(41:06):
for is what medications have been prescribedand have been paid by the employer carrier
right as compensable part of the claimto be able to figure out you know,
as the transition of the file goesthrough, you know, are there
medical records a substantiate that's no longerneeded, or the doctor is no longer
(41:28):
prescribing that that's been replaced with thisother medication, or that medication is no
longer you know, the need isno longer there because it's not providing the
relief necessary, right, And sothe doctor may be going down a different
road. That's why they want tosee those older records. They want to
figure out what has remained here,what has stopped, what has been replaced,
(41:51):
what other plants are there. Sothe combination of medical records and printed
payout from the pharmacy provides Medicare witha pretty good as to what that claimant
is now doing and may need downin the future. Another quick question,
heady, calculate the two hundred andfifty threshold payments for MSA, like,
(42:13):
do you include the past medicals alreadypaid the past indemnity or are we just
looking at the future payments in thesettlement agreement. So both the twenty five
thousand threshold and the two hundred andfifty thousand threshold, no past indemnity paid
benefits are includable in there. Nopast medical benefits paid are includable in there.
(42:35):
What we're going to throw into themix here is what are we settling
the file for, so everything futureand so we do throw in their indemnity,
we do throw in their medical wedo throw in their attorney's fees and
costs. Right, so everything that'spart of the overall global settlement that you
are working together here, that's what'sincludable in that either twenty five foul or
(43:00):
two hundred and fifty foul, youknow, depending on whether current medicare beneficiary
or soon to be within thirty months. Great, Well, as we're wrapping
up here, I want to kindof touch into what you kind of see
as the future of MSAS and CMShandling of those. You know, preparation
of MSA is all about looking forward. So in your mind, I know
(43:21):
you touched on this in terms offines that are coming down the pipe in
February twenty twenty four, is thatthe major development in terms of the world
of msas or what do you seeas the largest aspect coming our way?
So, right, I think Iwant to teach our industry to start talking
about Medicare Secondary payer instead of Medicareset aside. Right, And here's the
(43:45):
reason why Medicare Secondary pair is sortof the big ball of wax. Here
inside Medicare Secondary pair are three componentsthat we all need to be concerned about.
One is mandatory reporting that thousand dollarsper day per file. Right,
we need to make sure that thedata that we're communicating over to CMS is
(44:07):
accurate and it's timely, otherwise it'sgoing to get us into a lot of
trouble. Second thing that's part ofthat Medicare Secondary payer big ball here is
conditional payments the leans right, makingsure that as we walk away from this
case, we have reimbursed all ofthose conditional payments that Medicare has made throughout
(44:30):
the course of the file. Now, Medicare has gotten really really aggressive about
that. As of about five sixyears ago, they brought on a contractor
just to chase after employer carriers andTPAs and comp cases, not waiting around
until settlement. So if Medicare makesa payment today, Medicare has a record
(44:51):
of it. Then they give itto this new contractor, the Commercial Repayment
Center, and that CRC, theCommercial Repayment Center contract actor, chases after
that employer or carrier for reimbursement ofthat conditional payment. So that process is
new and it's aggressive. Right.This last report from the CRC shows that
(45:13):
over the last since twenty fourteen,they've recouped back over a million, over
a billion dollars right to the MedicareTrust Fund from workers comp cases alone.
So getting really, really aggressive onconditional payments. I think I already indicated
they're using the US Treasury, They'reusing the US Department of Justice to go
(45:34):
sue folks that haven't reimbursed conditional payments. So it's real, it's aggressive,
it's happening. So mandator reporting becauseof the obvious reasons, right, a
thousand dollars per day profile civil monetarypenalty and these conditional payments. And when
I say conditional payments, most ofus thinking ten, fifteen, twenty years
(45:55):
ago, we were only blindfolds onthinking about traditional Medicare. Today, over
fifty percent of all Medicare beneficiaries aregetting their Medicare coverage through a Medicare advantage
plan. Humanis United's sickness edness ofthe world. Right, if we do
(46:19):
not have a plan in place tonot only touch base with the traditional Medicare
system, but with these private plansthat are providing the Medicare coverage, that
we're missing half the battle here,Right, So you and I could settle
a file, nothing owe to Medicare. We're thinking, touchdown, we win.
Right. A year or two later, here comes Humana, Here comes
(46:42):
United, Here comes that Medicare advantageplan saying, hey, you settled it
two years ago, you never askedus, You owe me twenty thousand bucks.
I'm here to collect. Those entitieshave the same rights as the traditional
Medicare system to engage recoup and ifnot, to file suit for double damages.
(47:02):
Right. So, that mandatory reportingand the conditional payment side of things
is where I think I want theindustry to make sure you focus on that
Medicare set aside. You know,we've learned a great deal about it.
It is still a voluntary system.The things that are must absolutely mandatory is
(47:22):
that we report the file and thatwe reimburse conditional payments. So before we
talk about an MSA, let's talkabout reporting. Let's talk about conditional payments.
Because I think as an industry we'velearned really well and really are doing
a good job on this MSA stuff. It's these other two buckets that I
want to make sure industry is startingto learn a little more about and starting
(47:46):
to get more serious about. Yeah, well, I know that I have
clients ask about mssas all the time, and it's still an area that people
just really really struggle with because there'sso many different nuances to it. And
to see now that we've got thesepenalties coming, that's even more troublesome.
And I know our clients will probablykind of wake up to that. So
it'll be on us to kind ofget that word out to our clients to
(48:07):
make sure that they're on top ofall this. But I want to thank
you so much for taking the timetoday to come speak with us and sharing
all of your knowledge. I knowwe could probably continue down this road for
an hour or so, but it'sbeen a pleasure having you on it.
This is my first time getting tospeak with you about this, so I
know that I've learned a lot.But and you're a busy man. We're
(48:27):
two next for you. I'm headedoff to Florida RIMS here in a week
or so and then to SOCCA SouthernAssociation of Workers comp Administrators speak at that
conference as well. So July isis still busy as I'll get out.
And of course we've got WCI rightaround the corner here in August. I'm
(48:49):
looking forward to that as well.Great. Well, what's the easiest way
for our listeners to get in touchwith you if they want to learn more
about you or reach out to youand your services with Kaddy and Gonzalez.
Our website at ww Kaddy Gonzalez alwaysa good source and you can find our
email addresses and phone numbers and allof that there, so and of course
it's full of information. You're morethan welcome. I blog a bunch about
(49:13):
all of these issues and those areall published up there, and we try
to provide the industry with you know, that knowledge, the case law,
you know, the statutory stuff that'shappening all the time, so as to
be able to make sure that ourindustry stays up and what's going on in
all of this. And there arethere other ways to connect with you.
Social media. Yeah there is that, isn't there right, it's for an
(49:35):
old guy like me to I don'tknow how in the world this stuff with
the ralphies, you know, happened, but what an incredible thing. One
hundred thousand followers later, here weare living in social media and putting it
out and about every single day.So it's incredible for an old guy like
me. You know, this iswhat a world if for our listeners that
(49:59):
don't know. Ralphie is a Rafaelselfie and has become quite the spectacle on
LinkedIn. So too if you're tuneif you're tuning in and make sure you
go connect with him. He's gotplenty of content to share and as always,
has a ton of information. SoRafael, thank you again for your
time today. Thank you, Rafael. Thank you guys so much. What
a great honor. Thank you
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