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Were you aware that under Medicare Secondary Payer Law, Medicare does not pay for items or services that may be expected to be covered through other insurance? This may not seem important to know, but for those who end up in an accident that is covered by another insurance, you will want to know how this works ahead of time.

 

Basically, Medicare will cover bills for a liability or no-fault insurer if providers indicate they don’t expect to be paid promptly enough. It can take months or even years for auto accident or work comp claims to settle, and in the meantime, the providers need to be paid.

 

Under Medicare law, Medicare is authorized to pay providers and suppliers sooner on the condition that they will be reimbursed after the accident insurer makes good on the claim. Though most lawyers are familiar with this, people on Medicare often are not.

 

Montana SMP has seen several cases involving conditional payments, and as they are often settling years’ old claims, the cases are complicated, confusing, and time consuming. What would be easier is if people on Medicare understood at the time of service what to expect and what to keep track of. In an ideal world everything would just magically fall into place, but often instead you won’t know there’s a problem until you receive a notice from the Benefits Coordination and Recovery Center, (BCRC), that you are obliged to repay $12,000 in conditional payments or be referred to the Treasury Department to collect the debt.

 

The notices you receive would list the claims in question. In most cases, the trouble is multiplied because other Medicare claims are being intermixed, and now you must go through the process of proving which were and were not related to the accident. In the case of proving which were not related, this could be gathering hospital or doctor records that show the claim was unrelated to the accident. Once you’ve done that, those claims would be taken off the record.

 

The next step would be to get those legitimate conditional payments covered by the correct insurance carrier. If you took a settlement, it could be the insurance company considers it settled and you will be responsible for the remainder. (Note, if Medicare finds out you received a settlement and they went on to pay for services related to the accident after the fact, you will receive a bill that you have to pay yourself.) Or, you may have capped out on benefits where per their policy they won’t pay anything further, which you will need to show to Medicare in writing. It could also simply be that they never received those claims and they will pay them now. Lastly, it could be a mistake, and it won’t go away if you don’t clear it up.

 

In any of these scenarios, this means work for you. It’s better to understand now before you’re ever in this situation, so you can take a couple of steps to protect yourself from this headache.

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If you are ever in an accident and need to receive treatment, always be very clear at the time of service to your provider who to send the claim to. Likewise, if you receive treatment for anything not related to an accident when you have an open auto or other no-fault liability claim open, also be very clear that they should send it to Medicare and that it is not related to an accident.

 

Montana SMP received a case where a person had an old worker’s compensation claim still open from ten years ago that started wreaking havoc. If you are involved in an accident, always be sure to notify Medicare when that is settled and closed. If a provider checks the box when submitting the claim that indicates your claim was due to an accident, Medicare will tie it to any open accident on file, which is what happened in that case.

 

It's better to stay ahead of conditional payments and simply make sure the correct insurance pays at the time of service.

 

Montana SMP has some tools that can help you stay organized. This includes an envelope to track your Medicare Summary Notices, spreadsheets to help track your medical bills, and healthcare trackers to keep track of your appointments. If you need these tools, or have an issue you need help with, please contact your local SMP office in Montana by calling 1-800-551-3191.