Is Medicare Denying Payment for Treatment Under the MSP Act for Workers’ Compensation and Liability Claims?
by P. Czuprynski
The Medicare Secondary Payer (MSP) Act allows Medicare to make payment and then seek reimbursement for Conditional Payments. This occurs when Medicare asks for reimbursement associated with past payments made in relation to an incident.
The MSP Act also allows Medicare the option to deny payment for treatment, if Medicare believes there is another primary payer responsible for payment.
To assist Medicare in making these determinations, carriers and self-insureds are required to report Section 111 data. Reporting this data has been required since 2010 and may involve Ongoing Responsibility for Medical (ORM) or settlement reporting. Medicare’s conditional payment contractors use this data to search for potential conditional payments.
Section 111 data also makes its way to a claimant’s Common Working File. Medicare’s payment and billing systems uses the data in the Common Working File to issue payments and pre-authorize treatments.
While the data being used by Medicare is not new with respect to conditional payments, recently we have seen an increase in Medicare denying payment for treatment based on the Section 111 data submitted by carriers and self-insureds (or their Third-Party Administrators). Below are some elements to consider in these circumstances.
- Is Section 111 Reporting Data Accurate?
The carrier, self-insured, or their Third-Party Administrators (TPAs) may need to review their claim system and determine if any updates should be reported to Medicare.
Since updates to Section 111 data are usually transmitted quarterly, there may be a delay before an update is received by Medicare. If a reporting update will take some time, the carrier/self-insured may also want to consider sending a letter to Benefits Coordination & Recovery Center (BCRC) identifying the circumstances. Ideally, this information makes it into the claimant’s Common Working File and the treatment will no longer be denied by Medicare.
The provider may also need to resubmit their bill to Medicare or appeal Medicare’s denial. If the denial was informal, the provider may want to try again after updates are processed by Medicare.
- Has Claimant filed an “Unsolicited Response”?
A claimant or their representative may also file what is called an “unsolicited response” by calling the BCRC at 855-798-2627 or (855-797-2627 for the hearing and speech impaired). For example, if the claim was settled and closed out future medical rights, the claimant can advise Medicare of these circumstances in the unsolicited response. This information should then attach to the Common Working File. Medicare has a PowerPoint presentation on the unsolicited response process.
- Was Denial Informal or Formal?
“Box 10” in the standard HCFA 1500 form allows the medical provider to identify if the treatment is related to a workers compensation claim or third-party liability incident. If completed properly for unrelated treatment, this may increase the provider’s chances for payment by Medicare.
If there is a formal denial, federal regulations appear to only give the medical provider or claimant the authority to appeal a denial of payment. Therefore, a workers’ compensation or liability carrier may not be able to directly appeal a denial of payment and would need claimant’s authorization to do so. This places a heavy burden on claimant or claimant’s medical provider to resolve the issue with Medicare and obtain payment.
If Medicare has formally denied payment, this decision is called an initial determination and Medicare, or a Medicare Advantage plan, is required to send a decision letter. The Medicare beneficiary, or their provider, can appeal the initial determination. An appeal should be filed within 125 days of the formal denial of payment and follow the administrative appeal process outlined in 42 C.F.R. 405.900, et. seq. If from a Medicare Advantage Plan, the deadline may be less than 60 days and the decision letter should include a timeline to appeal.
If the denial is informal with no decision letter, there may not be an appeal process available. In these circumstances, the provider should still have the option to submit their bill to Medicare and make an appeal if formally denied.
Each case has its own complexities that can contribute to Medicare denying payment for treatment. The options discussed above are not guaranteed methods to resolve a denial of payment but rather are tactics we have seen used with success.
Should you have any questions or wish to discuss how IMPAXX can assist with denial of payments by Medicare, please contact our Settlement Consulting team at [email protected].