Medicare Issues Group Health Plan (GHP) Defense Reference Guide

by P. Czuprynski

Recently, Medicare issued a reference guide associated with conditional payment recovery related to group health plan claims. So, if a person has group health coverage AND Medicare coverage, Medicare may have a right to reimbursement against the group health plan.

The Group Health Plan (GHP) Defense Reference Guide Version 1.0 was issued on July 27 and provides a listing of potential defenses associated with group health plan collection. This is due in part to the fact that the Medicare Secondary Payer (MSP) Act can limit or preclude Medicare’s recovery where there is no reasonable expectation of payment under the plan or no demonstration of responsibility.

We encourage our readers to review the guide because it provides a list of potential defenses, and examples of supporting documentation and appeal letters. However, this guide may not cover all potential defenses and evidence that support a dispute. As with most conditional payment reviews, the major question is whether the charges listed by Medicare require reimbursement under the plan or settlement (if applicable).

If the answer to the question above is no, and you can support your dispute with documentation, Medicare should not require reimbursement. We regularly see Medicare agree to these principles when using their administrative appeal processes. Should you wish to discuss a conditional payment recovery, or have questions, please contact us.