Personal Injury Attorney Baltimore Guide to Medicare Reimbursement in a Personal Injury Claim

Medicare does not pay for items or services to the extent that payment has been, or may reasonably be expected to be, made through a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity (Non-Group Health Plan (NGHP). When an accident/illness/injury occurs, your personal injury attorney Baltimore must notify the Benefits Coordination & Recovery Center (BCRC).

The Benefits Coordination & Recovery Center (BCRC) is responsible for ensuring that Medicare gets repaid for any conditional payments it makes. A conditional payment is a payment Medicare makes for services another payer may be responsible for. Medicare makes this conditional payment so you will not have to use your own money to pay the bill. The payment is “conditional” because it must be repaid to Medicare by your personal injury attorney baltimore when a settlement, judgment, award, or other payment is made.

When you are presently on Medicare or will be eligible for Medicare within the next 30 months , there are  additional procedures required by Medicare for your personal injury attorney Baltimore to follow before you can receive your settlement money.  These procedures apply whether Medicare paid any of your bills or not.  Failure  to follow these procedures could jeopardize your rights to Medicare in the future.

When any person who is eligible for Medicare is injured in an accident, federal law requires Medicare be notified by your personal injury attorney Baltimore whether you have submitted bills to Medicare or not. The reason Medicare must be notified is not only so that they can be reimbursed for bills that are from the accident that Medicare has paid, but in addition Medicare wants to make sure they do not pay any accident related medicals in the future.

Federal law requires that Medicare be reimbursed up front for any related medical payments they may have made before any money from settlement can be disbursed to you or your personal injury attorney Baltimore .  This means that Medicare must be reimbursed before the client receives their portion of the settlement and Medicare must be reimbursed before the personal injury attorney baltimore  receives any fee for winning the case.

This blog article will outline the process required under Federal Law for Medicare reimbursement  by your personal injury attorney Baltimore.

This is necessary so that you and your personal injury attorney baltimore understand the timetable in which your settlement money will be disbursed, and so that you can assist us in getting through this process as quickly as possible. Federal Law requires you as well as your  personal injury attorney baltimore and the insurance company to complete this process before any money may be released. Federal law does not allow the injured party to excuse the personal injury attorney baltimore  from completing the requirements, nor does federal law allow the attorney to release the funds before the process is complete if the injured party agrees to be responsible for money owed to Medicare.

1. The case must be reported to Medicare. Your personal injury attorney baltimore  does not have to wait until your case settles to begin this first step.  Medicare should be notified immediately.
2. If the BCRC determines that the other insurance is primary to Medicare, they will create an MSP occurrence and post it to Medicare’s records. If the MSP occurrence is related to an NGHP, the BCRC uses that information as well as information from CMS’ systems to identify and recover Medicare payments that should have been paid by another entity as primary payer.
3. Medicare does not release information from a beneficiary’s records without appropriate authorization. If you have a personal injury attorney baltimore or other representative, he or she must send the BCRC documentation that authorizes them to release information. Your personal injury attorney baltimore  or other representative will receive a copy of the RAR letter and other letters from the BCRC as long as he or she has submitted a Consent to Release form. A Consent to Release authorizes an individual or entity to receive certain information from the BCRC for a limited period of time. With that form on file, your personal injury attorney baltimore  or other representative will also be sent a copy of the Conditional Payment Letter (CPL) and demand letter. If your personal injury attorney baltimore  or other representative wants to enter into additional discussions with any of Medicare’s entities, you will need to submit a Proof of Representation document. A Proof of Representation authorizes an individual or entity (including a personal injury attorney baltimore ) to act on your behalf. Note: In some special circumstances, the potential third-party payer can submit Proof of Representation giving the third-party payer permission to enter into discussions with Medicare’s entities. If potential third-party payers submit a Consent to Release form, executed by the beneficiary, they too will receive CPLs and the demand letter. It is in the best interest of both sides to have the most accurate information available regarding the amount owed to the BCRC.
4. Once the case has been reported to Medicare, Medicare will send out a Rights and Responsibilities Letter to both you and your personal injury attorney baltimore . When you receive this letter, please notify your personal injury attorney baltimore ‘s office.65 Days from the date that the Rights and Responsibilities Letter is received, Medicare is supposed to send out a Conditional Payment Letter. It frequently takes Medicare longer than 65 days to send out this letter.  This letter will contain the medical payments that Medicare believes they need to be reimbursed for.The BCRC begins identifying claims that Medicare has paid conditionally that are related to the case, based upon details about the type of incident, illness or injury alleged. Medicare’s recovery case runs from the “date of incident” through the date of settlement/judgment/award (where an “incident” involves exposure to or ingestion of a substance over time, the date of incident is the date of first exposure/ingestion).Within 65 days of the issuance of the RAR Letter, the BCRC will send the CPL and Payment Summary Form (PSF) to your personal injury attorney baltimore . The PSF lists all items or services that Medicare has paid conditionally which the BCRC has identified as being related to the pending case.The CPL explains to your personal injury attorney baltimore  how to dispute any unrelated claims and includes the BCRC’s best estimate, as of the date the letter is issued, of the amount Medicare should be reimbursed (i.e., the interim total conditional payment amount). The conditional payment amount is considered an interim amount because Medicare may make additional payments while the case is pending. If there is a significant delay between the initial notification to the BCRC and the settlement/judgment/award, you or your personal injury attorney baltimore  or other representative may request an “interim conditional payment letter” which lists the claims paid to date that are related to the case.
5. You or your personal injury attorney baltimore can also obtain the current conditional payment amount from the BCRC or the Medicare Secondary Payer Recovery Portal (MSPRP). To obtain conditional payment information from the BCRC, call 1-855-798-2627. Click the MSPRP link for details on how to access the MSPRP.
6. If a settlement, judgment, award, or other payment has already occurred when you first report the case, a CPN will be issued. A CPN will also be issued when the BCRC is notified of settlement, judgement, award or other payment through an insurer/workers’ compensation entity’s MMSEA Section 111 report. The CPN provides conditional payment information and advises you on what actions must be taken. You have 30 calendar days to respond. The following items must be forwarded to the BCRC if they have not previously been sent:
   • Proof of Representation/Consent to Release documentation, if applicable;
   • Proof of any items and services that are not related to the case, if applicable;
   • All settlement documentation if the beneficiary is providing proof of any items and services not related to the case;
   • Procurement costs (attorney fees and other expenses) the beneficiary paid; and
   • Documentation for any additional or pending settlements, judgments, awards, or other payments related to the same incident.

   If a response is received within 30 calendar days, it will be reviewed and the BCRC will issue a demand (request for repayment) as applicable.  If a response is not received in 30 calendar days, a demand letter will automatically be issued without any reduction for fees or costs. For more information about the CPN, refer to the document titled Conditional Payment Notice (Beneficiary) in the Downloads section at the bottom of this page.

7. If the Conditional Payment Letter is incorrect, then your personal injury attorney baltimore  must resolve the incorrect charges with Medicare. This process can take anywhere between 3 to 6 months depending on the nature and amount of incorrect charges that are on the Conditional Payment Letter.

If you or your personal injury attorney baltimore  or other representative believe that any claims included on CPL/PSF or CPN should be removed from Medicare’s interim conditional payment amount, documentation supporting that position must be sent to the BCRC. This process can be handled via mail, fax, or the MSPRP. Click the MSPRP link for details on how to access the MSPRP. The BCRC will adjust the conditional payment amount to account for any claims it agrees are not related to the case.

Please allow 45 calendar days for the BCRC to review the submitted disputes and make a determination. During its review process, if the BCRC identifies additional payments that are related to the case, they will be included in a recalculated Conditional Payment Amount and updated CPL. If CMS determines that the documentation provided at the time of the dispute is not sufficient, the dispute will be denied. You and your personal injury attorney baltimore  or other representative will receive a letter explaining Medicare’s determination once the review is complete.

5. If the Conditional Payment Letter is correct, then your personal injury attorney baltimore ‘s office will notify Medicare of the settlement and they will send a Final Demand Letter. The Final Demand Letter will be sent approximately 60 Days from the date Medicare is notified of the settlement.  If the Final Demand Letter is correct, then payment will be sent to Medicare for reimbursement and your settlement can be disbursed.
6. Demand Calculation Options- If you are settling a liability case or a workers’ compensation case, you may be able to request that your case be put into the Final Conditional Payment process. Please see the “Final Conditional Payment Process” section for more information.

   Optionally, if you are settling a liability case, your personal injury attorney baltimore  may be eligible to calculate the amount of money owed to the Medicare program (i.e. the demand amount) prior to settlement or you may be eligible to pay Medicare a flat percentage of the total settlement. Please see the “Self-Calculated Conditional Payment Amount” and “Fixed Percentage Option” sections to determine if your case meets the required guidelines. For information on how Medicare otherwise determines the demand amount for a typical liability, no-fault, or workers’ compensation case, see the Medicare’s Recovery Process page.

   Final Conditional Payment Process

   The Final Conditional Payment process permits your personal injury attorney baltimore  to obtain time and date stamped final conditional payment summary documents before reaching settlement and ensures that relatedness disputes are addressed within 11 business days of receipt of dispute documentation. This process, and all actions related to it, can only be requested on the Medicare Secondary Payer Recovery Portal (MSPRP). For more information see the MSPRP User Manual which is available under the ‘Reference Material’ menu option of the MSPRP application.

   Before initiating the Final Conditional Payment process it is important to note the following:

   • All Final Conditional Payment actions must be completed on the MSPRP
   • The process is only available for liability cases and workers’ compensation cases
   • Can only be started by the debtor (or debtor’s authorized representative) on the case
   • Can only be started ONCE per case
   • Notifies the Benefits Coordination & Recovery Center (BCRC) that the case is within 120 days of settlement
   • Guarantees that claim disputes submitted through the MSPRP are addressed within 11 business days
   • Limits disputes to once per claim / line item
   • Requires users to request the Final Conditional Payment Amount when the case is within 3 business days of settlement

   You will be required to complete the following actions for the Final Conditional Payment. Failure to complete any of these actions in time will void the Final Conditional Payment process and you will not be permitted to start the process again.

   1. Use the MSPRP to notify the BCRC that you are within 120 days of settlement
   2. Resolve disputes on the MSPRP during this 120-day period
   3. Request a Final Conditional Payment amount on the MSPRP within 120 calendar days of starting the Final CP process
   4. Settle the case within 3 business days of  requesting a Final Conditional Payment Amount
   5. Provide the settlement information on the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount

   Self-Calculated Conditional Payment Amount

   The Self-Calculated Conditional Payment Amount enables you to self-calculate the demand amount before settlement in certain situations. The following conditions must be met for Medicare to provide the demand amount before settlement is reached:

   • The claim and settlement must be for an injury caused by physical trauma. The settlement cannot involve or relate to injuries caused by exposure, ingestion, or medical implant.
   • Your medical treatment for the injury must be completed with no further treatment expected. Treatment must have been completed at least 90 days before you submit the proposed conditional payment amount to Medicare. These requirements are proven to Medicare by providing either: A physician’s written confirmation or Medicare beneficiary certification that he or she has not had care related to the case within the last 90 days and expects no further care.
   • The total settlement, judgment, award, or other payment cannot exceed $25,000.
   • The date of the incident must have occurred at least six months before submitting the self-calculated final conditional payment amount to Medicare.

   You will be asked to give up the right to appeal the amount or existence of the debt. However, you will keep the right to pursue waiver of recovery. For information on how to self-calculate the demand amount, please review the Self-Calculated Conditional Payment Amount Presentation available from the Downloads section near the bottom of this page. Here you will also find the Self-Calculated Conditional Payment Amount Model Language to be used when sending in the request.

   Fixed Percentage Option

   If a settled case meets certain eligibility criteria, you or your attorney or other representative may request that Medicare’s demand amount be calculated using the Fixed Percentage Option. The Fixed Percentage Option offers a simple, straightforward process to obtain the amount due to Medicare. It eliminates time and resources typically associated with the Medicare Secondary Payer (MSP) recovery process since you will not have to wait for Medicare to determine the conditional payment amount prior to settlement. You may elect the Fixed Percentage Option, if the following eligibility criteria are met:

   • Your liability insurance (including self-insurance) settlement, judgment, award or other payment is related to an alleged physical trauma- based incident and;
   • The total settlement is for $5,000 or less.
   • You elect the option within the required timeframe and Medicare has not issued a demand letter or other request for reimbursement related to the incident.
   • You have not received and do not expect to receive any other settlements, judgments, awards, or other payments related to the incident.

7. When there is a settlement, judgment, award, or other payment, you or your attorney or other representative should notify the BCRC. The information sent to the BCRC must clearly identify: 1) the date of settlement, 2) the settlement amount, and 3) the amount of any attorney’s fees and other procurement costs borne by the beneficiary (Medicare may only take beneficiary-borne costs into account). When submitting settlement information, the Final Settlement Detail document may be used. This document can be found in the Downloads section at the bottom of this page. Contact information for the BCRC can be found by clicking the Contacts link. Settlement information may also be submitted electronically using the MSPRP. Click the MSPRP link for details on how to access the MSPRP.

The BCRC will apply a termination date (generally the date of settlement, judgment, award, or other payment) to the case. The BCRC will identify any new, related claims that have been paid since the last time the CPL was issued up to and including the settlement/judgment/award date. Once this process is complete, the BCRC will issue a formal recovery demand letter advising you of the amount of money owed to the Medicare program. The amount of money owed is called the demand amount. The demand letter includes the following:

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A summary of conditional payments made by Medicare; and
The total demand amount and information on applicable waiver and administrative appeal rights.

8. If the Final Demand Letter is incorrect, then your attorney must resolve the incorrect charges with Medicare, and again this process can take anywhere between 3 to 6 months depending on the nature and amount of incorrect charges contained on the Final Demand Letter.

Interest accrues from the date of the demand letter and, if the debt is not repaid or otherwise resolved within the time period specified in the recovery demand letter, is assessed for each 30 day period the debt remains unresolved. Payment is applied to interest first and principal second. Interest continues to accrue on the outstanding principal portion of the debt. If you request an appeal or a waiver, interest will continue to accrue. You may choose to pay the demand amount in order to avoid the accrual and assessment of interest. If the waiver/appeal is granted, you will receive a refund.

Failure to respond within the specified time frame may result in the initiation of additional recovery procedures, including the referral of the debt to the Department of Justice for legal action and/or the Department of the Treasury for further collection actions.

Checks should be made payable to Medicare. All correspondence, including checks, must include your name and Medicare HICN and should be mailed to the appropriate address.

               7. Depending on the circumstances of your particular case, and any incorrect charges in which Medicare wants to be paid back for, the process to reimburse Medicare can take anywhere between 3 and 12 months after your case has been settled.  This process is required by Medicare, and failure to obey these Laws can result in penalties to the attorney and termination or delay of Health Insurance benefits from Medicare.  In short, there is no way around this process and all we can do is provide Medicare with the required information as quickly as possible and patiently wait until they give us permission to disburse the settlement.