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Check Medicare beneficiary status early in claims, expert recommends

Check Medicare beneficiary status early in claims, expert recommends

AUSTIN, Texas — Insurers and self-insured employers looking to settle workers compensation or liability claims should check a claimant's Medicare beneficiary status early in the settlement process to determine if Medicare should be reimbursed for medical payments, an expert told attendees at the American Society for Healthcare Risk Management conference.

Marla R. Ashford, risk operations director for the west Arizona region of Banner Health, a nonprofit hospital system based in Phoenix, offered tips Monday to help health care systems streamline the Medicare Secondary Payer process.

The Centers for Medicare and Medicaid Services requires insurers and self-insured employers to notify CMS of any workers comp or liability claim settlement involving a Medicare-eligible individual, and CMS can require that such payments reimburse the agency for medical care that it paid on behalf of a claimant. Observers say it sometimes can be difficult to determine if a claimant owes money to Medicare, and that challenges in the Medicare Secondary Payer process can delay settlements.

Ms. Ashford recommended that payers submit an electronic query to CMS in the earliest stages of a claim settlement to find out if it could be subject to Medicare reimbursement.

“I will know within eight to 10 days whether or not that's a Medicare beneficiary,” Ms. Ashford said. “By that time, I will have a good sense ... of whether or not I may even entertain a settlement.”

To ensure that payers don't have ongoing reimbursement obligations to Medicare after a claim has settled, Ms. Ashford recommended that settlement agreements include standard language that can protect payers from such liability. That includes a clause saying that the claimant is responsible for any Medicare liens or reimbursement claims that could be sent to the released settlement parties.


If medical treatment has been completed for a beneficiary's workers comp or liability claim, Ms. Ashford said payers should receive documentation from the claimant's physician stating that he or she no longer needs claim-associated medical care. This can prevent Medicare from holding payers responsible for unrelated medical treatments that occur after a claim is closed, Ms. Ashford said.

“I want to show to Medicare that I've done everything I could to determine that I don't need to take care of this patient any longer and I'm considering Medicare in my settlement,” she said.

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