MKC Medical Management recently participated in the annual WCI conference, Orlando, “a great way for me to stay current with top workers compensation issues,” Kari said. 

Our clients regularly turn to us for help with medically-related claims and cases that intersect with Medicare.  This is especially true for matters involving whiplash and other  bodily injuries following motor vehicle accidents, where we’re called on to review and analyze complex medical records and data.

That’s why a recent article caught my attention.  In it, the author, Quincy Enoch, made a compelling case why “insurance professionals who manage bodily injury claims stemming from auto accidents need to know their way around Medicare organizations.”

Enoch noted that ever since the passage of the Medicare Secondary Payer Act in 1980, Medicare comes into play, as he put it, because…

…a primary plan may not be able to immediately pay medical costs, such as a car accident or a work-related injury because the fault isn’t apparent, requiring an investigation or litigation to determine who is responsible for the medical costs. In these situations, Medicare is authorized to make conditional payments. However, these payments must be reimbursed by the responsible primary plan, and failure to do so could result in a severe penalty.

So what?

This is relevant because, Enoch notes, “it’s almost impossible for an insurer to determine whether it has a financial obligation to an MAO (i.e., a Medicare Advantage organization). There is no database for the insurance companies to check for beneficiary status of those enrolled in Medicare through MAOs, and, as a result of privacy laws, it’s often difficult for insurance companies to get beneficiary status even when directly contacting MAOs.

“Claimants also often try to hide beneficiary status from insurance companies, believing that because Medicare has already paid medical costs they may be able to keep the money included in a settlement meant to pay those medical costs.”

The result is that MAOs file suit and pursue double damages. Not only can they pursue this litigation without notifying insurance companies of the obligation, but they can also transfer the lien to another entity, extending that other, non-Medicare entity the same private right of action to pursue double damages.

As Enoch concludes, “This is essentially how Medicare Advantage recovery liens work and what insurance companies are facing on a more regular basis.”

So what to do?

  • Evaluate the MAO risk and potential financial implications.
  • Remember that Medicare programs comprise four parts and that these parts interplay and can, therefore, be confusing.
  • Double check the lien letters and determine all qualifiers and information.
  • Determine the injured party’s health insurance coverage — if possible — and any applicable coverages.  Information within the provider billing statements can be helpful here.
  • If possible, check with the providers for additional coverage
  • Consider using a med lien resolution service that can help answer questions and help with the process.

Finally, let me know if you have questions, comments…or just need to vent!

KARI