Medicare as a Secondary Payer

As a Social Security recipient, you eventually may be eligible for receipt of medical benefits through Medicare. You should be aware of the fact that Medicare is considered a secondary payer to several other payment options. In the event that you have additional health insurance, it is important that you review your policy to determine which insurance is primary for payment of medical benefits.

Should you be injured in the course of your employment or as a result of someone else’s negligence, such as a motor vehicle accident, generally Medicare is considered a secondary payer. This means that the workers’ compensation insurance carrier or your car insurance, through your personal injury protection (PIP), is the primary payer.

In the event that the treatment recommended is not approved by the workers’ compensation insurance carrier or your PIP coverage, Medicare may approve payment for same on a conditional payment basis. This essentially means that Medicare will pay for treatment, but seek reimbursement for same at the culmination of the case.

In a workers’ compensation matter, it may be determined that said treatment was reasonable, necessary and causally related to the industrial accident. If that is the case, it may be possible to have the court hold the workers’ compensation insurance carrier responsible for reimbursement to Medicare for the payments made. However, in the event that the court finds that the treatment is not such that would have been the responsibility of the carrier, it will then be necessary to reimburse Medicare from any recovery in the lawsuit.

In a claim for negligence, the treatment is generally provided through the injured party’s insurance. As a result, the reimbursement to Medicare for conditional payments is paid out of the injured party’s recovery.

It should be noted that the attorney representing the injured party has an affirmative obligation to contact Medicare to determine if any conditional payments have been made, and what those payments were. This is a very lengthy process. Initially contact must be made with Medicare. Thereafter, Medicare will forward forms for the attorney to complete. Upon receipt of all of the requested information, Medicare will forward correspondence indicating what conditional payments were made.

In the event that no conditional payments were made, correspondence reflecting same will be forwarded. In the event that conditional payments were made, Medicare will forward correspondence specifying what payments were made, to whom, when and what the treatment codes are for said treatment.

Despite the fact that Medicare is provided with the specific injuries and disabilities being claimed as part of the suit, the response from Medicare tends not to be specific to the injuries. Upon receipt, it is necessary for the attorney to sort through the conditional payments and further correspond with Medicare to attempt to alleviate the discrepancy. Only after there is a meeting of the minds between Medicare and the attorney, can the case be resolved.

As you may appreciate, this is a very lengthy and complicated process. However, it is a process that you must be aware of if you are currently receiving Medicare, or become Medicare eligible during the pendency of a claim for injury. Unfortunately, this process is mandatory for the attorneys involved, and not always understood by the injured party, as he or she is normally waiting for funds as a result of the resolution of a claim.