Addressing conditional payments in workers’ compensation cases adds an additional layer of complexity to the underlying claim.
“We are seeing Medicare be more accepting of the disputes of the underlying claim when Medicare is seeking collection directly against the carrier based upon Ongoing Responsibility of Medical (ORM) reporting. However, when Medicare is seeking collection based upon settlement, Medicare is less flexible in accepting the disputes of the underlying claim, unless you can show the treatment is unrelated to the settlement or claim,” says Patrick Czuprynski, director of Lien Resolution, NuQuest.
“However, medical records or ‘un-relatedness,’ by itself, are not required to disprove Medicare’s collection under the Medicare Secondary Payer Act. Medicare is required to prove there is a reasonable expectation under liability plan and a demonstration of responsibility.”
There are a range of common issues that can arise when Medicare is seeking reimbursement for payment. If there are multiple carriers, dates or injuries associated with a specific claim or settlement, in many cases, Medicare will open up a different case on each date of injury, carrier’s report or settlement.
“This means you could have Medicare seeking collection multiple times over one date of injury or even trying to collect twice over the same treatment,” says Czuprynski. “Cross referencing each claim or collection case by Medicare is a common complexity associated with these cases.”
Accurately determining the conditional payment amount requires following a defined process, as outlined below:
- Identify claimant is a Medicare beneficiary
- Obtain authorization from carrier/self-insured (sometimes claimant) to contact
- Contact Medicare, MAP or part D and request estimated lien
- Negotiate or accept estimated lien amount
- Notification to Medicare, MAP or part D of settlement
- Receipt of final lien
- Negotiate or accept final lien amount
- Payment pending appeal or payment and closure
- Receipt of closure letter
Although following these steps in order will play an important role in ending up with the most accurate - and fair – amount, Czuprynski does believe that insureds should start thinking about a conditional payments strategy as early as possible in the settlement process.
“A federal court has ordered a carrier to reimburse a Medicare Advantage Plan twice the amount of conditional payments after it paid settlement to the claimant, even though the claimant agreed to negotiate and reimburse the plan after it received the settlement money,” Czuprynski says. “This is a notice to the industry that your claim could face additional exposure if not investigated properly. The good news is that our data shows that Medicare’s collection is more likely than not over-inclusive. This means there is usually opportunities to reduce Medicare’s collection on every claim.”
NuQuest plays a crucial role in making the conditional payments process as simple and stress free as possible for clients. NuQuest, for example, has a dedicated team of legal staff whose sole focus is to investigate and negotiate conditional payments. This investment and focus has enabled the company to develop an expertise in dealing with Medicare-related phone calls, letters, faxes, and emails, as well as the rules Medicare uses to collect reimbursement.
“This provides a comprehensive investigation and negotiation with Medicare, MAP plan or Part D plan, but also exploits Medicare’s administrative appeal process and regulations,” Czuprynski says. “Having a team solely for conditional payments has also allowed us to experience almost anything that can happen during the collection process. There is rarely a situation or circumstance that is new or unfamiliar.”