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CMS enacts Medicare secondary payer appeals process


The Centers for Medicare and Medicaid Services has enacted a formal appeals process for workers compensation claim payers and others who want to contest reimbursements that must be paid under federal Medicare Secondary Payer rules.

The appeals process, effective April 28, was created as part of the Strengthening Medicare and Repaying Taxpayers Act, a bill enacted in 2013 that aims to ease the Medicare Secondary Payer compliance process.

The Medicare Secondary Payer Act requires insurers and self-insured employers to notify CMS of any workers comp or liability claim settlement involving a Medicare-eligible individual. CMS can require that such payments reimburse the agency for medical care that it paid on a claimant's behalf.

Under the new appeal rules, payers that are deemed to be a primary payer for a Medicare beneficiary's medical care can appeal the amount of reimbursement due or the existence of a debt to Medicare, according to a CMS statement posted online last week. Prior to the SMART Act's passage, payers had no right to appeal the amount or existence of CMS reimbursement demands.

Payers cannot appeal whether they are the correct party from which to seek reimbursement, CMS said in the statement.

“Requests for appeal on the basis that the applicable plan is not the correct debtor will therefore be dismissed,” the statement reads.

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