Conditional payments remain a problem for CMS

Workers compensation lawyer in Michigan breaks down the problem of conditional payments and encourages you to contact your elected representatives.

I recently came across a blog post from Jon L. Gelman, Esq. covering a hearing conducted by the Subcommittee on Oversight and Investigations.  The purpose of this hearing was to “examine the state of the current system and whether it adequately protects the interests of Medicare beneficiaries, businesses, health plans, taxpayers, and the Medicare Trust Fund.”

The primary issue discussed was how CMS is handling the conditional payment process. By way of background, “CMS may make a conditional payment for Medicare covered services where another payer is responsible for payment; however, CMS has the right to recover the amount of claims paid by the primary payer or anyone who has received the primary payment.”

This situation usually arises when medical bills that should have been paid under workers compensation are paid by Medicare. Reimbursement is required if workers compensation benefits are later recovered through an award or settlement.

Why conditional payments remain a problem in workers compensation

Everyone agrees that Medicare should be paid back for money that it spends that should have been paid by another party. The problem is how CMS has implemented its conditional payment recovery program.

CMS refuses to give a “final demand” until after a workers compensation case has been settled. This means that claimants must guess when it comes to the amount of any Medicare lien.

While CMS will provide a conditional payment letter before settlement, this amount cannot be relied upon.  In fact, our experience shows that this preliminary amount is frequently wrong because it fails to include all of the relevant charges.

CMS maintains in its testimony that their system works and that over 50 billion dollars has been saved. CMS believes that open communication as well as additional training and education is all that is needed to fix any problems.

We believe that CMS has a fundamental misunderstanding of how the practice of law works. The vast majority of workers compensation cases are resolved through settlement. A fair resolution cannot be negotiated without knowing how much Medicare must be reimbursed.

Additionally, CMS needs to take an active role in compromising its lien when the facts of the case show an unlikelihood of recovery. It does no good for claimants or the Medicare Trust Fund when a case cannot be settled and will be lost at trial.

A remarkable group of parties coming together for change

When insurance companies, big business, and trial lawyers all agree on something, there must be a serious problem. Medicare must be required to provide accurate lien information before a claimant settles his or her workers compensation case. Congress must act on this issue.

To speak with an experienced workers compensation lawyer, call (855) 221-2667 for a free consultation. We will make sure that your legal rights are protected and that you receive the maximum compensation under the law.

Alex Berman is the founder of the law firm. He’s been representing injured and disabled workers exclusively for more than 35 years.  Alex has helped countless people obtain workers compensation benefits and never charges a fee to evaluate a case.

Related Information:

Hearing: Protecting Medicare with Improvements to the Secondary Payer Regime

FAQs about workers compensation to help protect you

Workers compensation benefits denied or terminated

Photo courtesy of Creative Commons, by Images_of_Money.

07/01/2011
Injured On The Job: A Guide to Michigan Workers Compensation Law Injured On
The Job
A Guide to Michigan Workers Compensation Law Free Book
Free Consultation
  • This field is for validation purposes and should be left unchanged.