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Workers' Compensation Blog

Who Pays the Bill? Medicare or Workers’ Compensation?

Wednesday, October 31, 2018

Upon reaching the age of Medicare eligibility confusion abounds when determining if Medicare is the secondary or primary payer, especially if you have a prior workers’ compensation injury. Requirements have become more stringent on the workers’ compensation insurance companies to report claims to Medicare. As a result more recipients are receiving what is called conditional payment letters. A conditional payment from Medicare is a payment made even though it is another insurance company’s responsibility, of which they may seek reimbursement from the appropriate insurance company or the beneficiary.

Why does this happen and how will it affect you?

Primarily this occurs because it is easier for a provider to bill Medicare; all the systems are in place and they promptly pay their bills. Where the hospital is concerned Medicare might reject the claim as workers’ compensation related, even if there is no logical or medical connection to a prior workers’ compensation injury. In addition, once Medicare is notified that a workers’ compensation claim exists you may receive a letter in the mail from Medicare stating that they were notified that you have a workers’ compensation award. In the early stages this is purely an investigation by Medicare to determine if they paid for medical treatment that is actually the responsibility of the workers’ compensation insurance company. If Medicare determines through their own investigation that they have paid for treatment unnecessarily or made a conditional payment, they will seek reimbursement from the insurance company. Medicare may also sometimes seek reimbursement from the beneficiary and will notify them in the form of a conditional payment letter.

How do I know if it is a workers’ compensation related condition?

Another confusing situation is when you go to the doctor or hospital for what you thought was acid reflux, an unrelated condition, and it turns out you have hypertension, a related condition. Or when you go to the hospital for a heart condition, which is related, and the prognosis is instead an unrelated gastric condition. The priority is always to receive the medical treatment needed and then deal with who pays the bill afterward. It is imperative to retrieve all the medical records related to the condition and hospital stay from the hospital. These are documents that are specifically requested following your visit. This is not discharge paperwork, but the actual doctor notes and work-ups from your stay and/or visit. It is also helpful to ask your physician to comment specifically in the paperwork if in their medical opinion the condition is related to a prior workers’ compensation injury or it is unrelated. Finally, the notes should indicate the final determination of your diagnosis. Then, these documents can be used to help Medicare and your workers’ compensation insurance company determines the proper payer.

What do I do if I receive a letter from Medicare?

If a beneficiary receives a conditional payment letter it is important to respond in a timely manner indicating if it was in fact a workers’ compensation related medical expense and to include supporting documentation. Supporting documentation can come in many forms either as a denial letter from the workers’ compensation insurance company or commission, a letter from the beneficiary’s doctor, or medical records and a letter of explanation from the beneficiary. This process is another reason it is important to insure that a doctor’s office or hospital is billing the appropriate insurance company to save the beneficiary hours of work on the back end. However, the most important thing is to not panic. Remember it is a bureaucratic process that changes frequently and it is always a good idea to send a copy of the letter from Medicare to your attorney to review and to guide you in your response. If you are a previous client or current client with our firm we provide this service to you at no charge.

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