Personal injury cases are complex cases, but even more so when there is a Medicare lien attached to them. Unfortunately, it can be very difficult to get Medicare to release information, which makes these cases hard to manage. It is important, therefore, to know how to organize everything so that a settlement check is not held back, which could happen if a final demand from Medicare has not been made clear at the point of settling. Let’s take a look at the necessary steps to avoid this from happening.
1. Client Should Provide Medicare Information
It is vital that clients understand that the case may be delayed because of a Medicare lien. Hence, they must work together with their legal representation to be able to find out what Medicare benefits they can receive. A photocopy of both sides of their Medicare card should also be provided. The client should also provide copies of any correspondence with Medicare.
2. Contact the BCRC
The BCRC is the Benefits Coordination and Recovery Contractor for Medicare, which should be contacted straight away. It takes a lot of time to receive a response from the BCRC, which is why this should be the most immediate step and why all the right information should be provided. These include:
• HICN (Health Insurance Claim Number) and other details of the beneficiary
• Full information of the case itself
• The type of claim that is being made, including details of any insurance companies that are involved in the claim
• Information about the representative in the case
• A signed form as proof of representation and consent to release information
3. Await Confirmation
Once the case is opened, a Rights and Responsibilities letter should be sent out. This letter will also include a cover sheet with all reference numbers that must be used in future correspondence.
4. Submit Proof of Representation
Next, you must submit proof of representation, although you should already have included this with the initial contact. No action will be taken in a case without this letter, however, and Medicare is unlikely to tell you that any information is missing. This is why it is recommended that you send this form again. Legal representatives in these cases will often also sent a retainer agreement. However, this will only be accepted if:
• It is written on attorney letterhead and comes with a letterhead cover note.
• It was signed by the beneficiary.
• It highlights HICN details at the top.
• It is countersigned and dated by an attorney.
Medicare will also accept files without a retainer agreement. In this case, details must still be provided in order to prove representation. These include:
• The name of the client as shown on their Medicare card
• A copy of their HICN
• A letter confirming that the client has appointed such person as a representative
• A signature from the client and countersignature from the attorney, both dated
5. Await the Conditional Payment Letter
Once all documentation have been received, Medicare will start searching for any claims that are on the case. They will confirm their findings within no more than 65 days in their conditional payment letter. If no such letter is received after 65 days, it is vital that Medicare be contacted to find out what is delaying the issue.
6. Review the Conditional Payment Letter
A legal representative should properly review the conditional payment letter. This is because Medicare will sometimes include payments that are not related to the actual claim that is being placed. Additionally, it is not unheard of for them to make mistakes such as charging for the same thing twice. The letter comes with a full itemization and should therefore be checked properly.
Any unrelated claims should be clearly marked, either with an X or by crossing them out. Highlighting does not show up through their computerized system, which is something that they fail to mention themselves. Hence, the letter should be clearly marked before being sent back with a request to remove the various charges.
Alternatively, it is possible to calculate what is owed personally and send this to Medicare using the appropriate form, they will then respond with either agreement or disagreement within 60 days.
7. Monitor the Case
Unfortunately, in these cases, delays are common and frequent. Good legal representation will stay on top of the case and frequently contact Medicare to receive updates on the case and to ensure they continue to give it their full attention. Additionally, it is advisable to
call the Medicare Secondary Payer Recovery Contractor (MSPRC) at (866) 677-7220, if you have not received the documents you are waiting for, and the time period for producing them have passed. If they have other work to do though; wait times can be very long. MSPRC will not notify you if they are missing something, or if they have inadvertently misplaced what you sent. Stay on top and bug them until you get what you need.
Medicare is also in the process of setting up a self service portal on MyMedicare.gov, although it is not quite operational yet. Once fully functional, it will be an opportunity for people to check on their claims and make payments if they are due. However, there is no guarantee that using this portal will speed the process up in any way.
They have also launched the Medicare Secondary Payor Recovery Portal, which is designed for legal representation working on the case. This portal is designed to allow legal representatives to:
• Submit consent to release information and/or proof of representation.
• Request information on conditional payments.
• Dispute any information provided in the conditional payment letter.
• Submit information on case settlements.
8. Inform Medicare of a Received Settlement
Once a settlement is made in a case, Medicare should be informed of this straight away. They must know:
• How much the case settled for and when
• What the legal fees were, including a full statement
• Information about the liability insurer
• A copy of the agreement itself
This can either be done through a separate file, or by completing the Final Settlement Detail form.
Once this information has been received, a final demand will be generated. No settlement check will be issued until that point. This is why it is so important to include all the necessary information, so that no further delays are being made. In most cases, this takes at least one month, usually longer.
9. Watch Out for Tricks
Many people get so tired of waiting for the final demand that they put Medicare on the check itself. This is a huge mistake, however. Indeed, there is no legal requirement to do this as this is something that was settled legally in Tomlinson v. Landers (M.D. Fla. 2009) and Hearn v. Dollar Rent A Car (Ga. Ct. App. 2012).
10. Next Steps
When the final demand letter is received, the beneficiary can decide to pay it, appeal it, or request for it to be waived. It is very important to make a decision within 60 days, however, as interest will start to accrue on the balance if it is not paid. Appeals and requests for waivers must be done in writing, for which they have a standard form. But it is very rare for an appeal or waiver to be granted. Hence, most legal professionals will recommend that paying the final demand is the best way to finally close the case and move on.