Here is a basic step by step process of how your rights to Medicare benefits are handled when you are involved in an accident or incident when there may be other types of insurance available to pay some of your medical bills:
Step 1: Accident or incident occurs causing bodily injury.
Step 2: An ambulance comes, you go to the emergency room, get admitted to the hospital, see specialists, get diagnostic testing, receive surgery, therapy, medications, and whatever other treatment you need.
Step 3: Medical providers want to know all the insurance you may have. This includes auto insurance, workers compensation insurance, Medicare, Medicaid, and other health insurance.
Step 4: You or your representative provide all your insurance to the providers.
Step 5: If payments can not be made within 120 days, or only partial payments due to exhaustion of limited benefits such as auto medical insurance, the providers can and do bill Medicare, Medicaid, and other health insurance polices. Providers are required to bill primary medical insurance such as Florida no fault personal injury protection (PIP) coverage. Since these policy limits are only $10,000, that money gets exhausted quickly. Some auto policies sell supplemental medical coverage in the form of medical payments, or “Med Pay”, coverage.
Step 6: Medicare, Medicaid and health insurance policies pay the accident – incident related claims. Medicare typically, although not universally, requests proof that the underlying no fault or med pay insurance policy limits have been exhausted. When Medicare pays a bill that is related to an accident or incident, it does so under what is called a “conditional payment” and will try to get some of the money back from the insurance company or liability settlement. Medicare must issue an explanation of benefits to the insured and the provider as to what decision is made about payment in order to provide notice and due process of what is occurring with your benefits.
Step 7: Insurers, such as auto liability insurers, no fault, and general liability insurers, as well as attorneys must notify Medicare of the potential liability and other available medical claims so Medicare can attempt to coordinate benefits. This is done through the Medicare Coordination of Benefits office (COB) in Detroit. The COB then is supposed to refer the notice to the Medicare Secondary Payer Recovery Contractor (MSPRC) who is then in charge of managing any claims for reimbursements of alleged accident – incident related expenses paid by Medicare.
Step 8: Medicare through the MSPRC sends a rights and responsibilities letter to the Medicare recipient, any attorney or insurance company.
Step 9: The insurer or attorney sends MSPRC back a Trauma Development Code (TCD) form that identifies what specific injury diagnosis was caused by the accident, incident, collision, medical injury, etc. that makes up the liability claim.
Step 10: Medicare sends a payment summary form of what payments it has made that it claims are related to the accident – incident. Medicare sometimes includes claims in the payment summary form that are not related. For example, most Medicare recipients have at least one if not multiple chronic conditions or diseases that require various types of medical attention and treatment. Any bills that Medicare pays that relate to any type of pre-existing medical condition should not be included in the payment summary form. Also, injuries or conditions that are caused after the date of the accident – incident should not be included.
Step 11: The insurer or attorney can correspond back to Medicare requesting that the unrelated claims that were included in the payment summary form be removed from the payment summary form and thereby removed from the active MSPRC claim.
Step 12: Injury case gets settled.
Step 13: Medicare finalizes processing any and all accident – incident related claims and issues explanations of benefits forms to the insured and provider. Appeals may need to be taken with Medicare to enforce any rights of the Medicare beneficiary and providers to have medical bills paid. It’s my view that Medicare constitutes a fundamental constitutional right that can not be infringed upon. Doctor’s, hospitals, and other medical providers may get involved in the appeal process to ensure their claims get paid. The entire appeal process is completed inside the Centers for Medicare & Medicaid (CMS), a sub department of the Department of Health and Human Services (HHS) that governs Medicare. Once there has been an exhaustion of administrative remedies, a lawsuit could be filed in U.S. federal district court to enforce Medicare rights and the responsibility of Medicare to pay.
Step 14: Once any appeals are completed, a final demand letter can be requested from MSPRC.
Step 15: The amount claimed by MSPRC may be paid or appealed. Appeals can range from over payment arguments, under payment arguments, hardship cases and other equitable arguments. Once this appeal process is completed (exhaustion of administrative remedies) a lawsuit could be filed in U.S. federal district court to enforce rights to Medicare benefits.
Step 16: Once all the final determinations have been concluded, both as to the rights of the Medicare beneficiary and the duties of Medicare, the final payment can be made or adjusted and the case can be closed.
Thankfully, in July of 2012 CMS will be opening a portal for citizens on Medicare, attorneys and insurance companies to help streamline these efforts. This should be a very significant step toward making this process more effective for all parties concerned and help our nation improve a significant aspect of our public health care delivery program.