Medicare Third Party Liability
and Secondary Payer Law
Medicaid and Medicare Issues in Tort and Worker Compensation Settlements
Personal Injury Virginia Medicaid Lien Waiver Negotiations
A very brief primer:
“No-fault insurance or liability insurance pays first and Medicare pays second, if appropriate.
If the no-fault or liability insurance denies the medical bill or is found not liable for payment, Medicare pays the same as it would if it were the only payer. However, Medicare only pays for Medicare-covered services; you’re responsible for your share of the bill—for example, coinsurance, a copayment or a deductible—and for services Medicare doesn’t cover.
If doctors or other providers are told you have a no-fault or liability insurance claim, they must try to get payments from the insurance company before billing Medicare. However, this may take a long time. If the insurance company doesn’t pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should have made.
If Medicare makes a conditional payment, and you get a settlement from an insurance company later, the conditional payment from your settlement needs to go to Medicare. You’re responsible for making sure Medicare gets repaid for the conditional payment.
If you have an insurance claim for your medical expenses, you or your attorney should notify Medicare as soon as possible. If you have questions about a no-fault or liability insurance claim, call the insurance company.
If Medicare makes a conditional payment, you or your representative should call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627. TTY users should call 1-855-797-2627. The BCRC will work on your case, using the information you or your representative gives it to see that Medicare gets repaid for the conditional payments.
The BCRC will gather information about any conditional payments Medicare made related to your pending settlement, judgment, award, or other payment. Once a settlement, judgment, award or other payment is final, you or your representative should call the BCRC. The BCRC will get the final repayment amount (if any) on your case and issue a letter requesting repayment.”
Statutes, Regulations, and Register Resources
“Pursuant to 42 U.S.C. 1395y(b)(2(B)(ii)/Section 1862(b)(2)(B)(ii) of the Act) and 42 C.F.R. 411.24(e) & (g), CMS may recover from a primary plan or any entity, including a beneficiary, provider, supplier, physician, attorney, State agency or private insurer that has received a primary payment,” accessed at CMS “Attorney Services” page, June 21, 2015. (Note: on June 21, 2015, page reported that it had last been modified: 07/09/2014 12:54 PM.)
Code of Federal Regulations: 42 CFR Parts 405 and 411
Federal Register Publication of Secondary Payer Rule Making
Coordination of Benefits & Recovery Overview. This resource contains a table of useful links.
CMS Attorney Resources.
How to first report a case.
Proof of Representation and Consent to Release.
Conditional Payment Information, including limits ($300.00 / $25,000) for review, self service options, and the Medicare Secondary Payer Recovery Portal link.
Third Party Materials
2012 Outline, Gilbert, “Considering Medicares Interests in Third-party Liability Cases,” August 5 2013.
Medicare Secondary Payor Case:
Laska and CMS v. General Casualty Company (March 14, 2013, Wis. Ct. App).