MSPRC

The MSPRC will require your full name, date of birth, Health Insurance Claim Number (HICN)/Medicare Claim Number (located on your Medicare card below your name) and your address.

A signed and dated release of information or authorization form must be on file with the MSPRC before it will release information about a Medicare beneficiary. If the authorization form is on file, you will be requested to supply the following information about your client: their full name, their date of birth, their Health Insurance Claim Number (HICN)/Medicare Claim Number (located on their Medicare card below their name) and their address.

Please provide the following: your client's name, your client's Medicare Number, date of incident/accident, date of ingestion or date of illness, nature of illness/injury, name, address and policy number of the other insurance, other Medicare beneficiaries involved.

A refund will need to be sent to the Medicare Secondary Payer Recovery Contractor. You must notify the Coordination of Benefits Contractor at 1-800-999-1118 right away.

When Medicare is named as a payee on a check, all other payees must endorse the check. The check is then sent to the Medicare Secondary Payer Recovery Contractor for deposit. The Medicare Secondary Payer Recovery Contractor will distribute any excess funds it has collected over and above the debt.

Yes, your bills must be sent to your automobile insurance company before being sent to Medicare. Federal law requires that insurance that is primary to Medicare must pay first.

Conditional payment means a Medicare payment for services for which another payer is responsible. The Medicare Secondary Payer Recovery Contractor will provide listings of claims paid by Medicare that are related to an accident, illness or other incident. The total money paid by Medicare on one of these listing is called the conditional payment amount.

If the beneficiary/representative can prove that the claims are not related, the MSPRC will adjust the conditional payment amount to account for the claims they agree are not related to the incident.

Medicare makes a conditional payment as it would not be fair to the provider of service for Medicare and the other insurer to withhold payment. Some liability and workers compensation claims are not resolved for several years.

Medicare will make a conditional primary payment if it is expected that the primary payer will not pay in a timely manner (generally 120 days), Medicare may make a conditional payment.

Failure to repay your debt within the specified time frame may result in additional recovery procedures. Your debt may be referred to the Department of Justice for legal action and/or the Department of the Treasury for further collection actions.

Yes. Medicare is entitled to recover all payments made for items and services that were included in a beneficiary's claim against the liability, no-fault, or workers’ compensation insurance.

In a Medicare secondary payer situation involving liability, no-fault, workers’ compensation, Medicare may recover from any entity that has received the proceeds of any settlement, judgment, or award. This includes beneficiaries, their attorneys, providers, suppliers, Medicaid state agencies, and other entities.

No. Any reduction to a case is made in accordance with 42 CFR 411.37. Note that if there are no procurement costs (attorney fees and/or expenses) incurred in settling a case, Medicare will make no reduction.

When a Medicare provider of services learns that a beneficiary received services that may be payable by a payer primary to Medicare, the provider is required to pursue payment from the primary payer for a period of 120 days following the date of treatment. At the end of the 120 day period, if the insurer has not made payment, the provider may choose to bill Medicare or continue to wait for payment from a future insurance settlement. If the provider chooses to bill Medicare, then it becomes the Medicare Secondary Payer Recovery Contractors responsibility to recover Medicare’s payment if a settlement occurs at some point in the future. The provider of service is not required to send the bill to Medicare if they choose to pursue payment from a possible future insurance settlement.

No. Although some State laws may call for recovery to be reduced if the full value of a claim is not recovered, there is no comparable Federal Law or Regulation. Medicare will make a reduction if procurement costs are incurred as the result of a disputed claim. The Medicare reduction is made in accordance with 42 CFR 411.37.

The accident must first be reported to the Coordination of Benefits Contractor. The toll free telephone number to call is 1-800-999-1118. The Coordination of Benefits Contractor will provide further guidance.

When a Medicare beneficiary retains an attorney to represent him/her in a liability case, it is the attorney's responsibility to notify the Coordination of Benefits (COB) contractor by either telephone or mail. Their customer service representatives are available to provide you with service from 8:00 a.m. through 8:00 p.m., Eastern Standard Time, Monday through Friday. The toll free number to contact the COB Contractor is 1-800-999-1118 or TDD/TYY 1-800-318-8782 and the mailing address for written inquiries is: Medicare – Coordination of Benefits P.O. Box 5041 New York, NY 10274-5041

Yes. You should contact the Coordination of Benefits Contractor at 1-800-999-1118 or TDD/TYY 1-800-318-8782 right away.

If the owner of the home has a homeowner's insurance policy, it should be billed first.

Your employer’s Worker's Compensation insurance would be responsible for the claims.

Beneficiaries and their attorneys are obligated to notify Medicare when they make a claim against a liability, no-fault, workers compensation insurer. Medicare may also learn of such situations from providers, suppliers, insurers, and other parties. While most liability recovery files are established when attorneys contact COBC, others are started when Medicare receives positive feedback from the letters generated when trauma codes services are billed to Medicare. Still other files are started when Medicare’s COBC receives notice directly from beneficiaries (via phone call or written correspondence), when they receive notice from an involved insurance company or from counsel representing the responsible third party insurer (defense counsel).

Personal Injury Protection (PIP) and medical payments are considered no-fault insurance.

Include the items listed in the Workers' Compensation (WC) Medicare Set-aside Proposal Requirement Checklist. (WC Submission Checklist (PDF, 97 KB) (http://www.cms.hhs.gov/WorkersCompAgencyServices/Downloads/wcchecklist.pdf).

Yes, Medicare does have the right to make recovery on claims that are related to a pre-existing condition. When a Medicare beneficiary pursues a recovery action for accident related services, including services relating to an exacerbation of an underlying condition, the total amount of Medicare’s payments is used to calculate the amount of Medicare’s recovery.

No. At present, set-aside agreements only apply to Workers Compensation cases.

Providers are required to ask Medicare patients, or their representatives, at admission or start of care, if the services are for treatment of an injury or which resulted from an automobile or non-automobile accident for which he/she holds another party responsible. Normally, the provider would attempt to bill the indicated responsible party's insurance as the primary payer.

If a provider learns that an automobile medical or no fault insurance company may pay for covered services, it is expected to bill the insurance company as the primary payer.

Providers must bill the third party payer in liability situations. Providers have the option of requesting a conditional payment from Medicare if the third party payment will be delayed beyond 120 days. Under no circumstances should Medicare and another entity be billed at the same time. If the provider chooses to bill Medicare, it must withdraw claims against the liability insurer or the lien placed on the beneficiary's settlement.

Ordinary and necessary living expenses include items such fixed expenses as food, clothing, rent or mortgage payments, utilities, maintenance, insurances, and taxes. Also included are medical expenses not covered by Medicare, expenses for the support of others for whom the beneficiary is legally responsible, and other miscellaneous expenses considered necessary to maintain the beneficiary's current standard of living as it existed prior to the accident/injury/illness.

The Medicare Secondary Payer Recovery Contractor will always be the lead recovery contractor for new cases. However, the attorney should first contact the Coordination of Benefits Contractor (COBC) to establish the case. The COBC may be reached at 1-800-999-1118.

A beneficiary's death does not change Medicare's interest in recovery. The executor of the estate has the responsibility of concluding all business and financial matters remaining open at the time of the beneficiary's death. If a Medicare recovery claim was waiting on the outcome of a third party liability suit, Medicare would continue its claim against the estate.

If Medicare does not receive a full refund within 60 days of the date of the demand for repayment letter, interest will be assessed against the unpaid balance. Interest will be calculated retroactive to the date of the demand for repayment letter.

Yes, however, to avoid having to pay interest, you should repay Medicare in full within sixty (60) days of the date of the demand for repayment letter even if you decide to request a full or partial waiver of the amount owed. If waiver of recovery is granted, Medicare will refund the amount of the debt that is waived.

In order for Medicare to grant waiver of recovery of an overpayment, the beneficiary must be "without fault" in causing the overpayment. Based on the application of the Social Security Administrations definition of fault, found at 20 CFR 404.507, it is deemed that beneficiaries are without fault.

Medicare will take into account the impact of unexpected grave financial circumstances that occurred when Medicare requested repayment in addition to the beneficiary’s means to pay out-of-pocket medical expenses. Medicare may grant a full or partial waiver if recovery would negatively affect the beneficiary's standard of living compared to how it was before the accident/injury/illness.

Equity and good conscience refers to the total effect upon the beneficiary of granting or not granting a full or partial waiver. Some of the things the MSPRC will include when deciding what is relevant to "equity and good conscience" are: a. How much of a financial hardship the recovery will cause, b. How much the beneficiary's standard of living would be changed, c. If Medicare's recovery amount exceeds the settlement amount and, d. If the beneficiary is able to pay out-of-pocket accident related expenses that are not covered by Medicare.

Yes. If the waiver decision is denied or a partial waiver is granted, the beneficiary or attorney can request an appeal.

The Privacy Act of 1974 prohibits Medicare contractors from releasing a beneficiary's Health Insurance Claim Number (HICN), claims data, diagnoses, etc., without written authorization from the beneficiary.

Waiver of recovery should not be requested until the case is settled and Medicare has issued a demand for repayment letter. All requests for waiver of recovery must be submitted in writing.

Medicare can recover up to the total settlement minus the total procurement costs, 42 CFR 411.37 (d).

The money may be recovered through deductions from the beneficiary's Social Security benefits, Railroad Retirement Benefits, or other U.S. Treasury payments to which the beneficiary is entitled. Medicare may also recoup this money from anyone else that has been given money from the settlement, including the beneficiary’s attorney.

Medicare may recoup monies owed from any party that received a portion of the settlement proceeds.

Yes. A primary payer, or an entity that receives payment from a primary payer must reimburse Medicare for any payment if it is demonstrated that the primary payer has or had a responsibility to make payment. The primary payer’s responsibility for payment may be demonstrated by a judgment, a payment conditioned upon the recipients compromise, waiver or release whether or not there is a determination or admission of liability.

Medicare has no responsibility to pay for any claims related to a settled case that were incurred from the date of the incident until the day after the case was formally settled. Medicare has no responsibility for these claims as they should be paid for by the Medicare beneficiary out any settlement proceeds received.

The information needed includes, the total amount of the settlement, the date the settlement was signed, the amount of attorney fees and an itemization of additional procurement costs incurred in settling the case. This information must be submitted in writing to the MSPRC.

No. The only exception would be where payment of the benefits was contested. This occurs very infrequently.

When the MSPRC is informed of the settlement, judgment, or award, it will determine the amount of Medicare's recovery claim and send a recovery demand letter. Upon receipt of the demand letter, the attorney should repay Medicare.

Yes. If additional related claims are paid, the conditional payment amount will increase. Medicare's recovery claim is based on the amount of conditional payments made for related services that were incurred prior to the date of the settlement, judgment, or award.

Yes. Although Medicare has a right to recover an overpayment, waiver of recovery of the overpayment may be requested by the beneficiary or his/her representative. A waiver is exoneration of the debtor’s obligation to repay Medicare's claim, in whole or in part. Waiver of recovery may be granted, if certain criteria are met.

If the beneficiary lives in a 'no-fault' state or the beneficiary has medical payments coverage on his/her policy then that insurance would be primary to Medicare. If the beneficiary makes a recovery under an uninsured or under-insured provision of the policy, Medicare needs to be reimbursed for the accident related claims it paid.

If a liability insurer settles a claim with a beneficiary, it becomes the primary payer. Medicare will not assert a claim against the beneficiary for recovery of payments it has made until there is a settlement, judgment, or award in the case.

Waiver of recovery may be granted in cases where, financial hardship (as the result of the incident) is demonstrated or where recovery of the overpayment would violate the principles of equity and good conscience.

Yes. If the waiver request is denied, it may be appealed. The beneficiary or his/her representative may request a redetermination.