Medicare Conditional Payments

Most attorneys have had at least one case where resolving Medicare conditional payments delayed settlement. For most, they failed to understand the process. Cattie & Gonzalez has a deep understanding of what it takes to address a Medicare conditional payment in plenty of time so that the issue does not derail a settlement. Those steps involve the following:

Start Early – The most important practice tip this law firm can provide you is to start early. Once you know that you have a Medicare beneficiary involved and you anticipate there will some resolution of the claim (whether by settlement, judgment, or award), put Medicare on notice and request a conditional payment letter. Save the fight of whether you owe Medicare anything for a later date. It's better to err on the side of notifying Medicare too early of a potential reimbursement obligation as opposed to notifying Medicare too late.

Receive Initial Conditional Payment Letter – After first receiving a Rights & Responsibilities (R&R) Letter, the Medicare beneficiary and any authorized representative will receive the initial conditional payment letter. You can expect this process to take up to sixty-five (65) days or more from the date of the R&R Letter. This is an automated process, so calling Medicare to request expedited service will not help to speed things up.

Review Conditional Payment Letter – Upon receipt of the conditional payment letter, review the itemization carefully. Make sure everything listed is related to the compensable claim. Does the case involve a rotator cuff injury, but the itemization lists charges for a pre-existing heart condition that is not related to the case? This is your first (and best) chance to dispute those charges.

Disputing Unrelated Charges – To dispute unrelated charges, write a letter back to Medicare. Advise them which charges are not related to the case. Highlight those and circle them for the Medicare analyst to find easily. Include medical documentation to support your conclusions, if possible. Once sent back to Medicare, you can expect Medicare to take approximately forty-five (45) days to respond to your dispute.

Requesting Updated Conditional Payment Letters - When you start early enough, your case may not be close to resolution. Use this opportunity to request updated conditional payment letters every sixty (60) days. Repeat the process above (reviewing most recent itemization and disputing unrelated charges). As mediation approaches, you should have a clean (but for any items which have been disputed and Medicare disagrees) conditional payment letter. You now have a good idea what your maximum Medicare "lien" will be as you walk into mediation. However, understand that amount is not considered final by Medicare unless/until you settle the case.

Requesting Final Demand Letter - You settled your case at mediation, congratulations! Now is the time to ask Medicare for a final demand letter. Provide Medicare with settlement information (such as gross settlement value and date of settlement) along with an itemization of case costs/expenses. Within forty-five (45) days of your request, Medicare will issue a final demand letter. Immediately upon receipt of that letter, review it to determine: 1) how much Medicare is demanding for repayment; 2) when payment is due; and 3) whether all charges listed are related to the compensable claim.

Paying Medicare Back - If you agree with the amount that Medicare demands as repayment, write a check to Medicare and pay that within sixty (60) days of the date on the final demand letter. If the debt is not paid by then, interest will begin to accrue. If you disagree with the amount, you should likely still pay the amount demanded. But, make that payment under protest and advise Medicare that you plan to appeal its final demand figure. Pursuing a post-final demand appeal with Medicare is an entirely different process, falling under a completely different statute, and requiring a different set of skills to ensure success. For more information about Medicare appeals, click here.