Beware of Medicare Conditional Payment Demands

The Scenario
A claims administrator receives a Medicare Conditional Payment lien notice seeking reimbursement of $13,000 against an employee’s 2006 industrial knee injury claim. However the medical services provided had absolutely nothing to do with the knee injury but instead, were associated with a head trauma attributed to a 2010 non-industrial bicycle accident. The claims administrator was forced to either pay the claim or provide proof of non-liability.

Why This Could Happen To YOU
With the advent of MMSEA, workers’ compensation insurance companies, TPAs and employers are required to identify and advise Medicare of all claimants who are current Medicare beneficiaries. The Centers of Medicare and Medicaid Services (CMS) cross-match this information against medical bills paid by Medicare. Afterward, CMS sends out a notice of lien to the workers’ compensation administrator identifying the amount of Medicare Conditional Payments issue in behalf of any given claimant.

The Source of the Problem
Medicare does not check to determine if the Conditional Payments are related to the industrial injury. If any Conditional Payments are identified, regardless of the type of medical services provided, CMS demands reimbursement. It’s then up to the claims administrator to dispute or pay the lien. In addition, CMS does not describe the scope of medical services provided other than to list an ICD-9 code. The claims administrator must research each code to determine its relationship to the industrial injury.

The number of frivolous Medicare Conditional Payment reimbursement claims is staggering and continues to grow simply because Medicare fails to research claims prior to submitting a lien. Unfortunately many of these liens get paid because most claims adjusters and their attorneys do not have the expertise to deal with CMS.

Another Layer of Complexity
As a division of the federal government, any disputes involving CMS do not fall under the jurisdiction of the CA Workers’ Compensation Appeals Board. They fall under the jurisdiction of the Federal Courts. Most claims professionals and their attorneys have never dealt with CMS or the Federal Court system.

An Easy Solution
Resolution Partners is here to help! We have teamed up with legal experts experienced with CMS and Medicare Conditional Payment disputes. Do not automatically pay CMS liens. Most notices are inaccurate and seek reimbursement for Medicare payments issued for services unrelated to the industrial injury or for medical services where reimbursement is prohibited by the statute of limitations. Resolution Partners can analyze CMS lien notices and resolve disputes with CMS for you.

Also, make sure to check out our photocopy bill review services.