Medicare: Step-by-StepMedicare: Step-by-Step

How to process Medicare liensHow to process Medicare liens

Does this look familiar?Does this look familiar?

PurposePurpose

• Provide a practical framework for Provide a practical framework for paralegals working with Medicare liensparalegals working with Medicare liens

• History of Medicare’s right of History of Medicare’s right of reimbursementreimbursement

• Medicare’s position that it is a Medicare’s position that it is a – secondary payersecondary payer– Entitled to primary reimbursementEntitled to primary reimbursement

• How to request a reduction or waiver of How to request a reduction or waiver of lienlien

In 1965, Title XVIII of the Social Security Act In 1965, Title XVIII of the Social Security Act provided for creation of Medicare and provided for creation of Medicare and MedicaidMedicaid

HistoryHistory

• Provide medical insurance coverage to Provide medical insurance coverage to persons who receive Social Security persons who receive Social Security Retirement benefits or Social Security Retirement benefits or Social Security disability income. disability income.

• Not an entitlement programNot an entitlement program– Part A funded by payroll deductionsPart A funded by payroll deductions– Part B funded through monthly premiums Part B funded through monthly premiums

deducted from person’s monthly SS check.deducted from person’s monthly SS check.

Medicare Secondary PayerMedicare Secondary Payer

• Trust Fund established with these Trust Fund established with these funds to provide benefits for funds to provide benefits for beneficiaries’ medical carebeneficiaries’ medical care

• 1980 Congress passed Medicare 1980 Congress passed Medicare Secondary Payer law to insure trust Secondary Payer law to insure trust would have sufficient funds to pay for would have sufficient funds to pay for future carefuture care

MSP CriteriaMSP Criteria

• Medicare is Medicare is secondarysecondary payer if beneficiary payer if beneficiary has:has:– Group Health Plan Group Health Plan – Federal Black Lung ProgramFederal Black Lung Program– Veteran’s Administration benefits Veteran’s Administration benefits – On the job injuryOn the job injury

• Workers’ Comp pays for thisWorkers’ Comp pays for this

– Third party negligenceThird party negligence• Tort feasor pays and cannot shift the costs to Tort feasor pays and cannot shift the costs to

taxpayerstaxpayers

MSP CriteriaMSP Criteria, con’t., con’t.

– MedigapMedigap– MedicaidMedicaid– TRICARETRICARE– Federal Employee’s Compensation ActFederal Employee’s Compensation Act– Harbor Worker’s Compensation ActHarbor Worker’s Compensation Act

Medicare Coordination of Medicare Coordination of BenefitsBenefits [COB] [COB]

• Centralized office Centralized office – Investigate and ID other health benefits Investigate and ID other health benefits

available to beneficiaryavailable to beneficiary– Coordinate payment processCoordinate payment process

•Looks at injury codesLooks at injury codes

•Looks for trauma or injuryLooks for trauma or injury

http://www.cms.hhs.gov/COBGeneralInformatihttp://www.cms.hhs.gov/COBGeneralInformation/on/

. .

Conditional paymentsConditional payments

• Medicare Medicare maymay pay a beneficiary’s medical pay a beneficiary’s medical expenses conditioned upon expenses conditioned upon reimbursement to Medicare from proceeds reimbursement to Medicare from proceeds received pursuant to third party liability received pursuant to third party liability settlement, award, judgment or recovery.settlement, award, judgment or recovery.

• Conditional payment made where primary Conditional payment made where primary source can be reasonably expected to pay, source can be reasonably expected to pay, but not promptly. (Within 120 days)but not promptly. (Within 120 days)

• When payment is paid, Medicare entitled When payment is paid, Medicare entitled to reimbursement. to reimbursement.

Liability InsuranceLiability Insurance

• Uninsured motoristUninsured motorist

• Underinsured motoristUnderinsured motorist

• Homeowner’s liabilityHomeowner’s liability

• Product liabilityProduct liability

• Medical negligenceMedical negligence

ReimbursementReimbursement• If Medicare chooses to make conditional If Medicare chooses to make conditional

payments, its lien takes priority over every payments, its lien takes priority over every other lien, interest or judgment proceeds.other lien, interest or judgment proceeds.

• 42 U.S.C. 42 U.S.C. §1395(y)(b)(2) (Right to §1395(y)(b)(2) (Right to reimbursementreimbursement

• Title 42 C.F.R. 411.20 (How statute Title 42 C.F.R. 411.20 (How statute operates)operates)

• Zinman v. ShalalaZinman v. Shalala, 67 F.3d 841 (9, 67 F.3d 841 (9thth Cir. Cir. 1995) Medicare’s independent right of 1995) Medicare’s independent right of recovery upheld)recovery upheld)

• 42 U.S.C. §1395(y)(b)(2)(B)(ii) (Counsel for 42 U.S.C. §1395(y)(b)(2)(B)(ii) (Counsel for bothboth parties parties andand the insurer can be held the insurer can be held liable for twice the amount of Medicare’ lien liable for twice the amount of Medicare’ lien if its interests are not protected.)if its interests are not protected.)

Medicare/MedicaidMedicare/Medicaid

• Medicare’s subro rights are superior Medicare’s subro rights are superior to any other lien or interest, including to any other lien or interest, including MedicaidMedicaid– If beneficiary covered by both Medicare If beneficiary covered by both Medicare

and Medicaid, Medicare must be and Medicaid, Medicare must be reimbursed firstreimbursed first

– If amount due Medicare is equal to or If amount due Medicare is equal to or exceeds 1/3 of gross recovery, Medicaid exceeds 1/3 of gross recovery, Medicaid does not receive any recoverydoes not receive any recovery

– If Medicare lien is less than 1/3 gross If Medicare lien is less than 1/3 gross recovery, Medicaid can seek recovery, Medicaid can seek reimbursement up to 1/3 of gross recoveryreimbursement up to 1/3 of gross recovery

Medicare Prescription Drug Medicare Prescription Drug Improvement and Modernization ActImprovement and Modernization Act

• Medicare will not only screen Medicare will not only screen ICD-9/diagnosis codes relative to the ICD-9/diagnosis codes relative to the injury concerned, they will also screen injury concerned, they will also screen for any for any prescription drugsprescription drugs which they which they deem are associated with that same deem are associated with that same injury.injury.

• In some cases, a Medicare Set Aside In some cases, a Medicare Set Aside may be necessary for cases involving may be necessary for cases involving substantial future medical treatment substantial future medical treatment needs. needs.

Medicare: Step-by-StepMedicare: Step-by-Step

Step– by–StepStep– by–Step

• Determine if your client has Medicare Determine if your client has Medicare at the very beginning of your case.at the very beginning of your case.

Send in Letter of RepresentationSend in Letter of RepresentationWith Consent to Release FormWith Consent to Release Form

Send in information to COBSend in information to COB

• Certified Mail/Return Receipt Certified Mail/Return Receipt RequestedRequested

• Call- Get number to assigned MSPRC Call- Get number to assigned MSPRC Recovery ContractorRecovery Contractor

• Ask for name of person you speak toAsk for name of person you speak to

• Calendar- 10 daysCalendar- 10 days

MSPRCMSPRC

• Receive acknowledgment of your Receive acknowledgment of your representationrepresentation

• Receive Authorization to Release Medicare Receive Authorization to Release Medicare InformationInformation

• If you don’t receive w/in 10 days:If you don’t receive w/in 10 days:– CallCall– WriteWrite– Fax Fax – Calendar- 10 daysCalendar- 10 days

Return Authorization to Return Authorization to MSPRCMSPRC

• Mail via Certified Mail/RRRMail via Certified Mail/RRR

• FaxFax

• Call to be sure they receivedCall to be sure they received– Take name of person you speak toTake name of person you speak to

• Calendar- 14 daysCalendar- 14 days

Work your caseWork your case

• Gather medical records and billsGather medical records and bills

• Watch for unrelated medical Watch for unrelated medical treatment/billstreatment/bills

• Pay attention to ICD-9/diagnostic codesPay attention to ICD-9/diagnostic codes

• Pay attention to amount Medicare is Pay attention to amount Medicare is reimbursingreimbursing

Client at MMIClient at MMI

• Letter to MSPRCLetter to MSPRC– Client at MMIClient at MMI– Include final discharge/final diagnosis Include final discharge/final diagnosis

ICD-9 codesICD-9 codes– Include medical record which evidences Include medical record which evidences

conclusion of treatmentconclusion of treatment– ASK FOR PAYMENT SUMMARY FORMASK FOR PAYMENT SUMMARY FORM

FOLLOW UPFOLLOW UP

• MailMail

• FaxFax

• PhonePhone

• Calendar- 45 daysCalendar- 45 days

Payment Summary FormPayment Summary Form

• Audit formAudit form– Relevant treatmentRelevant treatment– Check dates of injuryCheck dates of injury– Check dates of serviceCheck dates of service– Check ICD-9 codesCheck ICD-9 codes– Highlight any payments that do not fit Highlight any payments that do not fit

your client’s criteriayour client’s criteria

Payment Summary Form, Payment Summary Form, con’tcon’t• HIGHLIGHTHIGHLIGHT those payments that are those payments that are

not relevantnot relevant• SUBTRACTSUBTRACT those payments from those payments from

Medicare’s totalMedicare’s total• WRITEWRITE your adjusted total on the your adjusted total on the

StatementStatement• PROVIDEPROVIDE copies of medical records copies of medical records

that back up your positionthat back up your position

Send packageSend package

• Send Medicare:Send Medicare:– highlighted copy of Payment Summary highlighted copy of Payment Summary

FormForm– Copy of medical records if necessaryCopy of medical records if necessary– Cover letter stating your total, asking for Cover letter stating your total, asking for

adjustment adjustment

SubmitSubmit

• MailMail

• FaxFax

• CallCall

• Calendar- 14 daysCalendar- 14 days

Mediation/Arbitration/TrialMediation/Arbitration/Trial

• Notify Medicare of any of these Notify Medicare of any of these eventsevents

• You will have good estimate of You will have good estimate of Medicare lien Medicare lien

SettlementSettlement

• Once case is resolved with third Once case is resolved with third party:party:– Prepare Settlement StatementPrepare Settlement Statement

• Itemized costsItemized costs

•Attorney feesAttorney fees

•Your estimate of what Medicare lien is/or Your estimate of what Medicare lien is/or Condition Payment LetterCondition Payment Letter

•Procurement costsProcurement costs

Procurement CostsProcurement Costs

Request Final Lien LetterRequest Final Lien Letter

• Send Settlement Statement to Send Settlement Statement to MSPRCMSPRC

• Request Final Lien/Payment letterRequest Final Lien/Payment letter

• Release of All ClaimsRelease of All Claims

• Fee ContractFee Contract

FOLLOW UPFOLLOW UP

• MailMail

• FaxFax

• CallCall

• Calendar- 14 daysCalendar- 14 days

Request Reduction/Waiver of Request Reduction/Waiver of Medicare LienMedicare Lien

• Beneficiary must be w/o faultBeneficiary must be w/o fault

• Recovery would effect financial Recovery would effect financial hardship, and/orhardship, and/or

• Recovery would be against equity Recovery would be against equity and good conscience using following and good conscience using following criteria:criteria:

CriteriaCriteria

• The degree of financial hardship caused by The degree of financial hardship caused by recoveryrecovery

• The extent the beneficiary’s state in life The extent the beneficiary’s state in life would be altered;would be altered;

• Medicare’s recovery amount exceeds the Medicare’s recovery amount exceeds the settlement amount; andsettlement amount; and

• The extent the beneficiary can meet non-The extent the beneficiary can meet non-covered, out-of-pocket accident-related covered, out-of-pocket accident-related expenses. expenses.

ExamplesExamples

SSA-632-BK FormSSA-632-BK Form

• www.ssa.gov/online/ssa-632.pdfwww.ssa.gov/online/ssa-632.pdf

• Complete form with relevant Complete form with relevant documentationdocumentation

• MailMail

• FaxFax

• CallCall

• Calendar- 120 days (from the date Calendar- 120 days (from the date the package is received by Medicare)the package is received by Medicare)

IMPORTANTIMPORTANT

• To avoid interest charges, the To avoid interest charges, the amount indicated by Medicare in amount indicated by Medicare in Final Lien Letter should be paid w/in Final Lien Letter should be paid w/in 60 days time limit.60 days time limit.