Lien resolution is no longer an administrative function. Each case demands a true strategy as the rules and protocols constantly change and evolve. Resolving Medicare liens can disrupt personal injury settlements consuming a firm's most valuable resources, leaving reimbursement claims unresolved from several months to over a year. We've compiled our 36 most helpful tips and guidance for resolving Medicare's reimbursement claims, including our most commonly asked questions.
While the tips that follow will assist with Medicare reimbursement on the higher volume of less complex cases, on the more serious injury cases, GRG can assist by navigating the changing regulations, processes and contractors to ensure these reimbursement claims are resolved.
So feel free to skip down to #36 and give us a call.
1. Whom should I (the plaintiff’s attorney) contact to notify Medicare of a reimbursement situation?
According to 42 U.S.C. §1395y(b), when a Medicare beneficiary retains an attorney to represent him/her in a liability case, it is the attorney’s responsibility to notify the Medicare Coordination of Benefits Contractor (COBC):
Medicare (COBC)
MSP Claims Investigation Project
PO Box 33847
Detroit, MI 48232
(800) 999-1118
For Workers Compensation cases, the attorney should notify:
CMS
c/o Coordination of Benefits Contractor
P.O. Box 33849
Detroit, MI 48232
2. What do all these acronyms mean?
CMS – Centers for Medicare & Medicaid Services
COBC – Coordination of Benefits Contractor
MSP – Medicare Secondary Payer – Division of CMS responsible for tort recovery
MSPRC – Medicare Secondary Payer Recovery Contractor
RO - CMS / Medicare regional offices
ReMAS – Recovery Management and Accounting System (centralized database used to identify Medicare’s conditional payments)
IRL- Intent to Refer Letter issued when payment has not been sent
3. What information should I provide?
Client’s name, address, DOB, client’s Social Security number and Medicare number, date of incident and type of incident (liability, no-fault, W/C, etc.), injury description (be as specific as possible & provide relevant ICD-9 diagnosis codes, if possible), the client’s name, address, and other information pertinent to other insurance (e.g. agent name, policy/claim number), your full name, address and telephone number as well as defense counsel name, address and telephone number.
4. What happens after I notify the COBC?
After the attorney has contacted the Medicare Coordination of Benefits Contractor regarding the representation of a Medicare beneficiary in a liability case, the COBC will assign the case to the MSP Recovery Contractor (MSPRC) and forward the attorney and beneficiary notification providing all contact information for the MSPRC. All written and telephone communication should be with the MSPRC once assignment has been made.
Note - Effective October 2, 2006, CMS awarded a contract for one national Medicare Secondary Payer Recovery Contractor, replacing the network of over a dozen separate regional contractors.
5. Where do I send my request for a conditional payment listing?
Once you have been notified by COBC that the case has been assigned send your request for lien information along with a signed HIPAA release via fax or regular mail to:
MSPRC Liability
PO Box 33828
Detroit, MI 48232-3828
Tel: 866-677-7220
Fax: 734-957-0998
Be sure to include the client’s name, Medicare number, date of injury and injury description (if possible provide the appropriate ICD-9 diagnosis codes). Once your correspondence is received at the MSPRC scanning facility in Detroit, they have up to 10 days to get it scanned into the system and sent to the MSPRC. The contractor then has up to 45 business days to respond, assuming they are not in a backlog situation. You may follow up on the status of your case by contacting the MSPRC call center at 1-866-677-7220. Unfortunately, at the time of publishing this booklet, it is no longer possible to speak to the MSP examiner working the case directly, hopefully that will change in the future.
6. Why is a signed Medical Record Authorization Release Form required before Medicare can release information to an attorney?
The Privacy Act of 1974 prohibits Medicare contractors from releasing a beneficiary’s Health Insurance Claim Number (HICN), claims data, diagnoses, etc., without written authorization from the beneficiary.
7. What role does the provider play in obtaining accident information from a Medicare patient?
Providers are required to ask Medicare patients, or their representatives, at admission or start of care, if the services are for treatment of an injury or which resulted from an automobile or non-automobile accident for which he/she holds another party responsible. This typically results in the boiler plate questionnaire being sent to the client requesting more information concerning a possible responsible third party. Normally, the provider would bill Medicare conditionally – However providers now have the right to bill the alleged responsible party’s insurance directly, in effect putting a lien on any possible future settlement.
8. Is the provider required to bill no fault insurance?
If a provider learns that an automobile, medical, or no fault insurance company may pay for covered services, it is expected to bill the insurance company as the primary payer.
9. Does Medicare pay claims and seek reimbursement or deny claims and require the primary insurance to pay?
If the other payer does not pay promptly, Medicare may make a conditional payment.
10. If the attorney representing a Medicare beneficiary was not notified of a Medicare payment of a claim(s) prior to the settlement, can Medicare still collect reimbursement?
Yes. Medicare may recover for all payments made for items and services that were included in a beneficiary’s claim against the alleged tortfeasor and/or liability, no-fault, workers compensation insurance.
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