This document provides a step-by-step process for paralegals to handle Medicare liens when a client has received a settlement from a third party. It discusses Medicare's right to reimbursement for conditional payments made on behalf of beneficiaries. The process involves notifying Medicare of representation, gathering medical records, submitting documentation for payment summaries, negotiating adjustments, and requesting a final lien amount or reduction/waiver of the lien prior to disbursing settlement funds.

1. Medicare: Step-by-Step How to process Medicare liens

2. Does this look familiar?

3. Purpose Provide a practical framework for paralegals working with Medicare liens History of Medicare’s right of reimbursement Medicare’s position that it is a secondary payer Entitled to primary reimbursement How to request a reduction or waiver of lien

4. In 1965, Title XVIII of the Social Security Act provided for creation of Medicare and Medicaid

5. History Provide medical insurance coverage to persons who receive Social Security Retirement benefits or Social Security disability income. Not an entitlement program Part A funded by payroll deductions Part B funded through monthly premiums deducted from person’s monthly SS check.

6. Medicare Secondary Payer Trust Fund established with these funds to provide benefits for beneficiaries’ medical care 1980 Congress passed Medicare Secondary Payer law to insure trust would have sufficient funds to pay for future care

8. MSP Criteria Medicare is secondary payer if beneficiary has: Group Health Plan Federal Black Lung Program Veteran’s Administration benefits On the job injury Workers’ Comp pays for this Third party negligence Tort feasor pays and cannot shift the costs to taxpayers

9. MSP Criteria , con’t. Medigap Medicaid TRICARE Federal Employee’s Compensation Act Harbor Worker’s Compensation Act

11. Medicare Coordination of Benefits [COB] Centralized office Investigate and ID other health benefits available to beneficiary Coordinate payment process Looks at injury codes Looks for trauma or injury http://www.cms.hhs.gov/COBGeneralInformation/ .

12. Conditional payments Medicare may pay a beneficiary’s medical expenses conditioned upon reimbursement to Medicare from proceeds received pursuant to third party liability settlement, award, judgment or recovery. Conditional payment made where primary source can be reasonably expected to pay, but not promptly. (Within 120 days) When payment is paid, Medicare entitled to reimbursement.

13. Liability Insurance Uninsured motorist Underinsured motorist Homeowner’s liability Product liability Medical negligence

14. Reimbursement If Medicare chooses to make conditional payments, its lien takes priority over every other lien, interest or judgment proceeds. 42 U.S.C. §1395(y)(b)(2) (Right to reimbursement Title 42 C.F.R. 411.20 (How statute operates) Zinman v. Shalala , 67 F.3d 841 (9 th Cir. 1995) Medicare’s independent right of recovery upheld) 42 U.S.C. §1395(y)(b)(2)(B)(ii) (Counsel for both parties and the insurer can be held liable for twice the amount of Medicare’ lien if its interests are not protected.)

15. Medicare/Medicaid Medicare’s subro rights are superior to any other lien or interest, including Medicaid If beneficiary covered by both Medicare and Medicaid, Medicare must be reimbursed first If amount due Medicare is equal to or exceeds 1/3 of gross recovery, Medicaid does not receive any recovery If Medicare lien is less than 1/3 gross recovery, Medicaid can seek reimbursement up to 1/3 of gross recovery

16. Medicare Prescription Drug Improvement and Modernization Act Medicare will not only screen ICD-9/diagnosis codes relative to the injury concerned, they will also screen for any prescription drugs which they deem are associated with that same injury. In some cases, a Medicare Set Aside may be necessary for cases involving substantial future medical treatment needs.

17. Medicare: Step-by-Step

18. Step– by–Step Determine if your client has Medicare at the very beginning of your case.

20. Send in Letter of Representation With Consent to Release Form

22. Send in information to COB Certified Mail/Return Receipt Requested Call- Get number to assigned MSPRC Recovery Contractor Ask for name of person you speak to Calendar- 10 days

23. MSPRC Receive acknowledgment of your representation Receive Authorization to Release Medicare Information If you don’t receive w/in 10 days: Call Write Fax Calendar- 10 days

24. Return Authorization to MSPRC Mail via Certified Mail/RRR Fax Call to be sure they received Take name of person you speak to Calendar- 14 days

25. Work your case Gather medical records and bills Watch for unrelated medical treatment/bills Pay attention to ICD-9/diagnostic codes Pay attention to amount Medicare is reimbursing

27. Client at MMI Letter to MSPRC Client at MMI Include final discharge/final diagnosis ICD-9 codes Include medical record which evidences conclusion of treatment ASK FOR PAYMENT SUMMARY FORM

28. FOLLOW UP Mail Fax Phone Calendar- 45 days

29. Payment Summary Form Audit form Relevant treatment Check dates of injury Check dates of service Check ICD-9 codes Highlight any payments that do not fit your client’s criteria

30. Payment Summary Form, con’t HIGHLIGHT those payments that are not relevant SUBTRACT those payments from Medicare’s total WRITE your adjusted total on the Statement PROVIDE copies of medical records that back up your position

31. Send package Send Medicare: highlighted copy of Payment Summary Form Copy of medical records if necessary Cover letter stating your total, asking for adjustment

32. Submit Mail Fax Call Calendar- 14 days

33. Mediation/Arbitration/Trial Notify Medicare of any of these events You will have good estimate of Medicare lien

34. Settlement Once case is resolved with third party: Prepare Settlement Statement Itemized costs Attorney fees Your estimate of what Medicare lien is/or Condition Payment Letter Procurement costs

35. Procurement Costs

36. Request Final Lien Letter Send Settlement Statement to MSPRC Request Final Lien/Payment letter Release of All Claims Fee Contract

37. FOLLOW UP Mail Fax Call Calendar- 14 days

38. Request Reduction/Waiver of Medicare Lien Beneficiary must be w/o fault Recovery would effect financial hardship, and/or Recovery would be against equity and good conscience using following criteria:

39. Criteria The degree of financial hardship caused by recovery The extent the beneficiary’s state in life would be altered; Medicare’s recovery amount exceeds the settlement amount; and The extent the beneficiary can meet non-covered, out-of-pocket accident-related expenses.

40. Examples

41. SSA-632-BK Form www.ssa.gov/online/ssa-632.pdf Complete form with relevant documentation Mail Fax Call Calendar- 120 days (from the date the package is received by Medicare)

42. IMPORTANT To avoid interest charges, the amount indicated by Medicare in Final Lien Letter should be paid w/in 60 days time limit.