If Medicare has not paid for any treatment a beneficiary received, do any settlement payments to the beneficiary need to be reported?

Question: If CMS states that there is no lien on a given claimant's settlement, or in other words, Medicare has no interest in the settlement proceeds because it has not paid anything for medical treatment in connection with the injury at issue, then do the parties have an obligation to report the settlement to Medicare? In this instance, the claimant is a beneficiary and the settlement amount is above the reporting threshold and the settlement releases medical claims – but it seems unnecessary to protect Medicare’s interest, because Medicare says it does not have a lien.

Answer: The Responsible Reporting Entity (“RRE”) is required to report the settlement, under the provisions of Section 111, if the claimant is Medicare enrolled at the time of the settlement and the threshold for reporting is met; regardless of whether there is a lien to be resolved. Section 6.5.1 of Chapter III, Version 4.0 of the User Guide states that “Information is to be reported for claims related to liability insurance (Including self-insurance), no-fault insurance, and workers’ compensation where the injured party is (or was) a Medicare beneficiary and medicals are claimed and/or released or the settlement, judgment, award or other payment has the effect of releasing medicals.” There is no exception for a case where there are no liens to be resolved.

This conclusion is further supported by the fact that Medicare even requires MMSEA reporting on a settlement where the claimant had not incurred any medical expenses but where medicals were released. Medicare provides, in Section 6.2.5.1 of Section IV, a “no-injury” (NOINJ) code that RREs must use in the settlement where the claimant did not seek medical treatment. Medicare’s requirement for reporting is based on whether “medicals are claimed and/or released or the settlement, judgment, award or other payment has the effect of releasing medicals.”