Group Says Comp Insurers Face New Fed Snare

Payment for emergency care of undocumented aliens was authorized by the 2003 Medicare Modernization Act which created the new Medicare drug benefit.

Under Section 1011 of the MMA, the Centers for Medicare and Medicaid (CMS) will administer a fund to compensate hospitals and physicians for emergency care to undocumented aliens.

Eric Oxfeld, president of the UWC, explained that, in the case of workers who are American citizens, the comp system has a fee schedule that limits what hospitals can charge for emergency care, but under the new act this would not be the case for undocumented workers.

Hospitals, he said would be able to charge their normal fee levels, which might be above workers' comp guidelines, when treating undocumented workers. After receiving payment from comp insurers, the hospitals could bill the undocumented workers for the difference, according to Mr. Oxfeld.

Facing substantial hospital bills for the balance, "the worker would run to an attorney" and sue the employer or insurer, Mr. Oxfeld forecast.

The Centers for Medicare and Medicaid are having an Aug. 2 forum on the subject in Baltimore with an accompanying conference call at 1-800-837-1935- a conference I.D. number 849891. Final written comment is due no later than Aug. 16. The statutory date for implementing the undocumented aliens program is Sept. 1.

Text of the proposal is available online at: //www.cms.hhs.gov/providers/mma1011.pdf.

CMS is proposing that hospital providers not request section 1011 alien treatment reimbursement where payment has already been made or could reasonably be expected to be made by a federal, state or local government plan or where third-party reimbursement such as workers' compensation, liability insurance, no-fault insurance or an employer group health plan will provide reimbursement for eligible services.

Since the Medicare Modernization Act does not put a limit on hospital charges, CMS proposes that a provider be allowed to "balance bill" for claims that are not fully paid by another insurer.

UWC said it has verified with CMS that this provision is intended to allow "balance billing" of a workers' comp claimant or beneficiary of any other third party payment system for amounts above what is payable by the comp insurer.

However, UWC notes that, "with rare exception, workers' compensation laws do not permit balance billing, and instead pay for all reasonable and necessary care."

A UWC statement said that "CMS policies and procedures should not circumvent and effectively supersede state workers' compensation laws."

Balance billing, UWC said in an e-mail to insurers and employers, "is not only adverse to the interests of injured workers, it can also stimulate unnecessary litigation by driving claimants to retain legal counsel".

UWC said it will be submitting comments asking CMS to clarify that nothing in the new program authorizes balance billing for care covered by workers' compensation, and it urged its members to send their own comments.