There are special rules for people who are injured in accidents, and who have Medicare insurance benefits. It is important for anyone who is on Medicare and involved in an accident consider what Medicare’s legal interest may be in their case. The rules (and there are consequences for breaking them!), are there to make sure that Medicare doesn’t pay for expenses that are being paid for by another insurance company as part of a settlement or legal process.
Medicare’s interest extends to medical bills that have already been paid, as well as to medical expenses that might occur at some point in the future. There is an entire government office, called the Centers for Medicare & Medicaid Services (CMS), that deals with these issues. Another term for this is Medicare subrogation.
There are two things that must be taken into consideration:
- Is Medicare going to seek reimbursement for any medical expenses paid?
- Is Medicare going to require that some portion of a settlement or court award be used for future related expenses?
If Medicare determines that they have paid medical bills that are included as part of a settlement or court award, then Medicare will expect to be reimbursed. Sometimes this isn’t easy to do, especially in situations where an accident may have aggravated a pre-existing injury, or there is some dispute as to whether or not an injury was even caused by the accident in the first place. Many injury claims are settled “on a disputed and contested basis”, meaning that there may never be a clear agreement as to what injuries or medical expenses are included.
If there is a possibility of future medical expenses, then Medicare’s interest must also be considered. This is again difficult in situations where the settlement doesn’t clearly indicate what portion is for future medical expenses (almost no settlement does this). There are also many situations where the settlement is based on disputed liability.
We consider both of these issues for our clients so that they can avoid any further complications, penalties, or loss of benefits from Medicare. We associate specially trained medical record examiners to help create the type of documentation that Medicare needs to show that our client remains in compliance with the rules. Additionally, we look for any opportunities to minimize the portion of a settlement or legal recovery that must be paid back to Medicare so that our client can keep the largest portion of their settlement possible.