Medicare Conditional Payment FAQs

How long does a provider have to bill Medicare?

Providers have 365 days from the date of service to submit the bill/claim to Medicare. If for any reason the provider submits an untimely claim, they cannot bill the beneficiary except for copays/deductibles.

How long does it take to resolve a Medicare "lien"?

This won't be the answer you want to hear, but it depends. Some cases can be very easy as there are little to no conditional payments which appear. Some cases are complex with a long list of expenses to review. Some of those expenses could be unrelated to the case at hand. When you ask Medicare to remove those unrelated items, it could refuse to remove them. You might choose to take additional steps to remove those.

Assuming all things go according to plan and there are no surprises, you should expect it to take approximately 90-120 days to resolve the average Medicare conditional payment obligation for Parts A and/or B. Remember that Medicare Part C (aka Medicare Advantage) and Medicare Part D (aka prescription drug plans) have an entirely different process, and are not addressed directly with CMS.

Find out more

Why did our Final Demand figure go up?

Everytime you ask Medicare for an updated conditional payment figure, it gives Medicare the chance to search the beneficiary's common working file for more claims submitted by providers for reimbursement. When Medicare receives a request for a final demand figure, it understands this is the one final chance to find all items it believes are related to the case at hand. Combine that with the fact that medical providers have up to 365 days from the date of service to bill Medicare, and the result, from time to time, is a final demand that is higher than any previous conditional payment.

Can I Rely on the Conditional Payment Figure as a Final "Lien" Figure From Medicare?

You could, but that would be a dangerous practice. Figures contained in conditional payment letters are just that: conditional. Medicare's right of recovery under the MSP Act does not ripen unless or until there is a settlement/judgment/award. For this reason, you cannot get a final "lien" number from Medicare pre-settlement. Simply put, Medicare does not yet have a recovery right at that point in time. By relying on a conditional payment figure as a final "lien" number, you are setting yourself up for the potential that the final demand figure from Medicare comes back higher than the conditional payment figure. If the parties have not planned for this contingency, then it could potentially derail a settlement and/or set up the Medicare beneficiary for sending all net proceeds to Medicare.

There is one path to relying on a conditional payment figure with certainty. Those who use the Medicare Secondary Payer Recovery Portal (MSPRP) have the ability to rely on a conditional payment figure as final, under certain circumstances. These circumstances are set forth by regulation at 42 C.F.R. § 411.39. While use of this regulation can be very helpful, its application is complicated. If you'd like to use this regulation to help resolve your Medicare conditional payments more efficiently, please call us at (844) 546-3500. 

What Do I Do If I Disagree With Medicare's Final Demand Figure?

Medicare's final demand figure does not always align with our belief of what that should be. However, once the final demand letter is sent, the clock is ticking. From that date, you have 60 days to pay the amount, accurate or not, before interest begins to accrue.

At that point, the question becomes one of proportionality and finality. How much do you dispute? Is it 1-2 small charges, or is it thousands of dollars? It might make sense to pay a small, unrelated charge in order to get the file closed. If the amount in dispute is large, it might make sense to begin the post-demand appeals process. Click the button below to learn more about that.

In either case, it makes sense to pay the amount Medicare asserts. Even if you intend to submit an appeal later, paying that amount now means interest cannot accrue. While you may win your appeal (and be reimbursed for your payment up front), you also could lose. Having to pay interest on top of the amount owed simply because you thought Medicare was wrong would be insult added to injury. You can prevent that from happening by paying the amount under protest, and then filing a timely appeal. Cattie can help with that process.

Find out more

What Happens If I Ignore This and Do Not Repay Medicare Conditional Payments?

In today's age, this question is more theoretical than practical. Most settlements have procedures agreed to by the parties to ensure repayment will occur. However, there are outliers. Let's assume your case is an outlier.

Under federal law, Medicare has a right to collect the following:

  1. the amount of the final demand it asserts (1x);
  2. the amount of the final demand it asserts plus interest (1x + interest);
  3. double the amount of the final demand (2x);
  4. double the amount of the final demand plus interest (2x + interest); or
  5. treble damages plus a per claim penalty of up to $22,363 under the federal False Claims Act.

In 2018, Medicare proved that recovery under the False Claims Act was possible. In our article titled "Your Compliance Will Be Rewarded: USDOJ Settles Case With Plaintiff Law Firm for Failure to Repay Medicare Conditional Payments", we detailed how Medicare referred cases to the United States Department of Justice (USDOJ) to collect repayment.  So, think twice before you decide to ignore Medicare's recovery rights under the MSP Act. If you need help navigating the process, please let us know.