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  • Medicare Coming to Disabled or Injured Beneficiaries for Reimbursement?

    Many Medicare beneficiaries expect, and usually rightly so, that once a Medicare claim has been paid, there’s no reason for them to think about it again. For beneficiaries with other coverage, however, or who may receive a settlement due to an accident or injury for which their employer or another person is liable, it’s important to understand when and how Medicare may pay, and when they may seek reimbursement from the beneficiary.

    The Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2012 establishes Medicare as secondary payer in cases where a beneficiary is covered by a designated primary payer — either a group health plan, liability insurance, no-fault insurance, or a worker’s compensation plan. If claims are paid with Medicare as the primary payer and it’s later determined that some other party should have been primary, Medicare will seek reimbursement either from the other responsible party or from the beneficiary directly. Medicare ultimately has the final say in whether the person or company liable for the claim or the beneficiary themselves is responsible for the reimbursement. While this can theoretically impact any of your clients who may find themselves with additional coverage or with an accident or injury settlement, it’s disproportionately likely to affect those who are Medicare eligible due to disability, as they’re more likely to have an insurance settlement or ongoing responsibility for medicals agreement. It’s easy for clients to see the potential to have Medicare come to them for reimbursement of claims that have already been paid as a source of great anxiety, but there is some basic information that you as their agent can offer to help them understand whether they may be asked to reimburse Medicare, and how the process may play out for them.

    Correct billing can save a lot of headaches – Most doctor’s offices are familiar with how to coordinate benefits for patients who have coverage through multiple sources, but it’s good to get your clients into the habit of reviewing and saving their Explanations of Benefits and any bills they receive from their doctor’s office. It’s also important that clients know to specify to their doctor’s office if particular coverage should be charged or the bill submitted to a particular company if it changes from visit to visit. For example, if a client has both a work related back injury and an unrelated ankle issue and seeks treatment through the same orthopedist, he or she will likely need to specify on each visit who to bill for treatment to avoid the potential to have to reimburse Medicare.

    Medicare will provide conditional payment for services – Medicare will pay claims presented for treatment on behalf of current beneficiaries without concern for whether the cost may later be found to be the responsibility of another party. Once Medicare determines that another payer has primary responsibility for the claim, they’ll seek reimbursement from whover is deemed the responsible party. What this means is that if a Medicare beneficiary needs to seek treatment as a result of an injury or illness that they believe will be determined to be the fault of another party, they should still seek treatment promptly and have the claim processed by Medicare if they have not yet received a judgement or do not yet know who the primary payer will be. Claims can be settled up later, the first concern should be to get the care they need.

    Medicare can provide information on reimbursement amounts to parties settling claims in advance – If a member is in the process of negotiating a settlement or having a judgement determined as a result of an injury or illness that is the fault of another party, they can request information on the amounts for which Medicare will seek reimbursement in advance, so that that can be taken into consideration.

    There is an appeals process – If an individual beneficiary is identified as the debtor for the purposes of reimbursement, they have a right of administrative appeal and judicial review. It can, understandably, be a lengthy process, but it’s important for people to know that the appeals process is there before they feel forced to pay a bill for which they believe they are not responsible.

    Medicare does not need proof that the claim was as a result of a particular injury or incident to seek reimbursement – The wording of the statute does not require Medicare to have proof that a claim is for treatment of a particular injury or illness that is the fault of another party. Medicare is only required to demonstrate proof that another party has primary payment responsibility. Especially in the case of insurance settlements where ongoing responsibility for medicals is included, there may be some room for interpretation of whether a particular claim should be covered by Medicare as the primary payer or not.

    Medicare paying second doesn’t mean they won’t pay at all – Medicare being the secondary payer doesn’t mean they won’t pay any claims. It simply means that they’ll pay after the primary payer has covered whatever they’re responsible for, essentially the same way that a Medicare Supplement plan pays after Original Medicare has picked up their share. If there are things that Medicare would cover that for whatever reason the primary payer won’t, those services would still be covered by Medicare.

    While this isn’t a situation that you can probably expect to see very often amongst your clients, if at all, it is something to be aware of. Having Medicare asking for reimbursement of claims that have already been paid can cause a lot of stress and worry for your clients, and knowing enough to help them understand the process can go a long way towards keeping them happy and, for that matter, keeping them as clients.