The Great and (Simultaneously) Terrible Medicare, Part III

Ron Swanson's attitude is pretty similar to that of Medicare, if you think about it.

Ron Swanson's attitude is pretty similar to that of Medicare, if you think about it.

Let's review, shall we?

Yes, let's! In our last two installments on Medicare, we learned that the Program is a creature of federal law providing various types of health insurance coverage for various types of people here in the United States. We learned that Medicare is a secondary payer, meaning that it won't kick in any payment for your medical bills until all other sources of coverage are exhausted. We learned that if Medicare paid for injuries suffered due to the negligence of somebody else, then the Program has a right of reimbursement against your personal injury recovery, and that right of reimbursement is going to attach to pretty much any form of coverage. Finally, we learned about notice requirements for medical providers, insurance carriers, and attorneys, as well as the fact that Medicare doesn't have to do much of anything to perfect its right to reimbursement.

Today, we're covering two very important topics; (i) how to set up your claim with Medicare, and (ii) how to audit Medicare's asserted right of recovery.

When should I start setting up my claim?

 You need to reach out and set your claim up as soon as possible. Federal entity that it is, the Program doesn't work quickly, and you're not going to get them to work any faster. It therefore behooves you to give Medicare as much time as possible to figure out their right to reimbursement. Otherwise, you might find yourself twiddling your thumbs while you wait on Medicare to catch up.

Who do I reach out to in order to set up my claim?

I normally write an introductory letter to the Program, and send it to Medicare-COB, MSP Claims Investigation Unit, P.O. Box 33847, Detroit, Michigan 48232-5847. Within about 2 to 4 weeks, Medicare will assign an investigator to the claim. You can also call or even go online to set up your claim, but old-fashioned me prefers to keep everything in writing as I'm able.

Claims processing.

Once COB and the Medicare Secondary Payer Recovery Center (MSPRC) are notified that a beneficiary has been injured and incurred resulting medical expenses, the case file will be opened and processing will begin. The first steps you'll see the Program take are: (i) send a Rights & Responsibilities Letter to the beneficiary, (ii) review all paid expenses to identify the ones that resulted from the injury at issue, and (iii) send the beneficiary a Conditional Payment Letter setting forth the asserted right of reimbursement.

Rights & Responsibilities Letter.

The Rights & Responsibilities Letter, or "RRL," basically tells the beneficiary what information the Program is going to need in order to process the claim. Typically, this is going to include a Proof of Representation (but only if you have an attorney; since this article is geared toward pro se claimants, we're not going to cover that today), the identity and contact information for any involved auto insurance carriers, and details of any settlement. Importantly, the RRL is also going to include a cover sheet that should be used for any correspondence that you send to MSPRC. If you don't use a cover sheet, you need to at least use the assigned case or HIC number.

Conditional Payment Letter.

The Conditional Payment Letter, or CPL, is just that; conditional. Because of the ongoing nature of medical treatment and the length of time it takes to receive and review a full complement of medical records, the CPL sets forth the amount of money that Medicare claims to have paid up to the date of the letter. Keep in mind that the CPL isn't a request for payment. It's just Medicare's assertion of what amounts they've paid for your care up to the present. MSPRC can't provide you with a final amount and demand for payment until after you arrive at a resolution.

Reviewing the CPL.

Remember the trusty ICD9/ICD10 codes that we keep talking about? Well, that's what the Medicare examiner is going to use to determine what medical services were related to your accident. It then follows that the Program's asserted right to recovery is going to be directly related to what diagnosis codes appear on your bills. This way of doing things is reasonably reliable, but it isn't foolproof. Therefore, you absolutely must audit the CPL very carefully to make sure that there aren't any unrelated treatments on there. If there are, you're going to end up paying Medicare back with money that isn't included as a part of your settlement.

Updating the CPL and other closing matters.

Medicare will not automatically send you updated CPLs. You need to ask them to send these updates to you periodically, in writing, to make sure that you're staying abreast of their asserted right of reimbursement. You can also do this via your account on www.MyMedicare.gov

In closing, keep in mind that Medicare's right of recovery isn't going to be affected by practically anything. Settlement agreements, mediations, arbitrations, and even State court decisions aren't binding on Medicare, because Medicare preempts all those things as a federal creature. 

This is complicated stuff! If you're over your head, call an attorney!