Step-by-Step Guide to Medicare’s Recovery Process

By Amy E. Bauccio, Lawyer at Metzger Wickersham

Happy Birthday, Medicare! Let’s celebrate Medicare’s 55th birthday (July 30) this week and give it the limelight it deserves because Medicare plays an important role in personal injury cases. It is often a form of health insurance for individuals who were injured as the result of another’s negligence. Generally, Medicare is available for people age 65 or older, younger people with disabilities, and people with end-stage renal disease (ESRD).

If you are a Medicare recipient with a personal injury claim, Medicare may pay for medical treatment related to the claim. Under the Medicare Secondary Payer (MSP) Act, Medicare is considered a secondary payer when payment has been made by a “primary plan.” Primary plan is worker’s compensation law or policy, liability insurance (including self – insureds), and no-fault insurance. If a primary plan has not, or cannot be reasonably expected to make payment promptly, Medicare may make a “conditional payment’ on behalf of the primary plan. Conditional payments are conditioned upon reimbursement from the primary plan, or an entity that receives payment from a primary plan (e.g., a beneficiary or attorney), if the primary plan has or had a responsibility to pay for those same items and services.

There are important procedures and rules to follow in a case with a Medicare recipient:

  1. Contact Medicare’s Benefits Coordination and Recovery Contractor (BCRC). The BCRC collects the information for Medicare and opens the file with Medicare Secondary Payer Recovery Center (MSPRC). The BCRC can be contacted bytelephone or by mail. Information that needs to be provided includes beneficiary information, case information, and representative information.
  1. Once BCRC opens the case, a Rights and Responsibilities Letter is generated that outlines the process.
  1. Proof of Representation needs to be sent to the MSPRC.
  1. A Conditional Payment Letter should be received within 65 days. The MSPRC will search for claims paid related to the case and then issue a Conditional Payment Letter as well as a Payment Summary Form that will list all payments that Medicare believes are related to the case and for which they are seeking reimbursement. The itemization in the Payment Summary Form needs carefully reviewed for any unrelated claims. A letter may be faxed to MSPRC asking them to remove the unrelated charges and include a copy of the itemization with the crossed out unrelated claims.
  1. When there is a settlement, judgment, award, or other payment, you or your attorney or other representative should notify the BCRC. The information that needs to be submitted includes the date and amount of settlement as well as attorneys’ fees and costs. When submitting settlement information, the Final Settlement Detail document may be used. Settlement information may also be submitted electronically using the Medicare Secondary Payer Recovery Portal.
  1. The case settlement information is used to generate Medicare’s final demand. Medicare’s final demand amount will account for the reduction for a share of attorneys’ fees and costs. A check must be sent within 60 days or interest will accrue.
  1. If you disagree with the final demand amount you can appeal or request a waiver in writing. Upon receipt of the request, MSPRC will ask you to fill out a waiver form. 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.

The process can be difficult but you do not want to disregard your obligation to notify and reimburse Medicare for conditional payments. If you are a Medicare recipient and believe that you have a personal injury claim contact one of Metzger Wickersham’s personal injury attorneys who are experienced in dealing with Medicare. Call us at (888)-286-2850 or email us to schedule your free consultation today.