Q&A: I received the Final Demand from Medicare. What is the proper reimbursement amount?



Question: After final demand request Medicare sends there Demand amount which is only about 10 % of what we were expecting. They appear to have all the charges listed but tiny amounts paid. When we checked MyMedicare earlier they had some much larger amounts listed as payments for certain big hospital charges. Safe to just pay what they want and be done?

You’re not the first to be in this position. Knowing the proper amount to reimburse Medicare for conditional payments made (date of injury to date of settlement) is a tricky proposition, especially when you begin to think about the statutory remedies available to the federal government for failure to repay those conditional payments (including but not limited to double damages plus interest as well as potential treble damages pursuant to the federal False Claims Act [31 U.S.C. §§3729, et seq.]. Getting it right up front is important so as to allow you to close the file with confidence knowing that the federal government will not pursue your client or your firm for any additional dollars post-settlement.

Here, your facts indicate that all claims potentially submitted to Medicare have 1) been recognized by Medicare and 2) been listed by Medicare in the final demand letter. The charges related to those items, however, are much smaller than you indicated. The fact that all claims have been listed is important. You have afforded the federal government the chance to assert a reimbursement claims for all charges and it has done exactly that. At this point, you should be able to close the file with confidence (with respect to past medicals to Medicare) after making payment to Medicare for the amount requested. Should you (via your client’s request) wish to take a more conservative approach, you could always pay and appeal (asking Medicare to review the bills again and provide a final figure). The hazard there is opening yourself up to a potentially larger figure. Based on the facts here, I think you’re safe to pay and close the file with respect to the Medicare conditional payment issues on the file. I cannot speak to other potential liens on the file or any potential future medical or MSA issues which may be associated with the file.

On cases like these, you often find yourself trying to manage the risk of these reimbursement issues (liens and/or future medicals) in a manner that best protects your client and your law firm. Clients that work with us in a comprehensive fashion are able to resolve liens more quickly, disburse funds more quickly and close files more quickly, all while knowing that they have transferred all risk of these reimbursement issues away from them and onto us.

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