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MEDICARE SECONDARY PAYER (MSP) FREQUENTLY ASKED QUESTIONS AND ANSWERS FROM ATTORNEYS

1.How do I notify Medicare of a possible lien or other MSP situation?
-When reporting an MSP situation, you should notify the Coordination of Benefits Contractor (COBC) at the address or phone number below. The COBC will add an MSP auxiliary record to the beneficiary's Medicare records, and determine which Medicare contractor will take lead responsibility for handling the case.
Medicare - Coordination of Benefits Contractor
MSP Claims Investigation Project
P.O. Box 125
New York, New York 10274-0125
1-800-999-1118
2.What should be included in the letter to Medicare?
-Please include the following information:
-Your Name
-The Medicare beneficiary's name
-The Medicare beneficiary's Health Insurance Claim Number (HICN)
-Date of Accident
-Type of accident (i.e. slip and fall, auto accident, etc.)
-Status of case
-Projected time frame for settlement
-Description of your client's injuries
-Signed Letter of Representation
-Signed Release of Information Agreement
3.What would happen if I did not notify Medicare of a possible lien situation?
-Section 1862(b) of the Social Security Act grants Medicare a priority right of recovery. This section also gives the Medicare program the right of subrogation for any amounts payable to the program under Section 1862 of the Act. In order to recover the conditional payment, Medicare may bring direct action in its own right against the entity responsible or required to pay Medicare, or against any other entity that has received payment. In addition, Medicare has, under subrogation law, a right to recover its payment from an individual or other entity that received payment from a third party payer.
4.What is the difference between Part A and Part B?
-Part A is a Medicare beneficiary's hospital insurance.
-Part B is a Medicare beneficiary's medical insurance, which provides partial reimbursement for physician office visits and certain other services.
5.Does Medicare reduce its claim by the attorneys' fees and costs?
-Medicare may reduce the amount it is owed by a pro rata share of the procurement costs in liability cases. The formula for this reduction can be found at 42 C.F.R. Section 411.37.
6.Is Medicare willing to waive its claim amount entirely/partially?
-Medicare contractors have the authority to consider a Medicare beneficiary's request for waiver on behalf of HCFA, under 1870(c) of the Social Security Act. HCFA may waive all or part of its recovery in cases where an overpayment under Title XVIII has been made with respect to a Medicare beneficiary:
(a) Who is without fault, AND
(b) When adjustment or recovery would either:
   (1) Defeat the purpose of Title II or Title XVIII of the Act,OR
   (2) Be against equity and good conscience.
-Waiver requests must be submitted in writing to the designated lead contractor. Upon receipt of your request, the lead contractor will send you an Overpayment Recovery Questionnaire (HCFA Form 632-BK). This form must be filled out in its entirety, include supporting documentation, and submitted to the lead contractor for consideration. Waivers cannot be requested until Medicare has determined the total Medicare amount (both Part A and Part B) and your claim against the third party has been finally resolved
7.What does Medicare need from my client in order to process the waiver?
-Waiver requests must be submitted in writing to the designated lead contractor. Upon receipt of your request, the lead contractor will send you an Overpayment Recovery Questionnaire (HCFA Form 632-BK). This form must be filled out in its entirety, include supporting documentation, and submitted to the lead contractor for consideration. Waivers cannot be requested until Medicare has determined the total Medicare amount (both Part A and Part B) and your claim against the third party has been finally resolved.
-The Medicare beneficiary must submit supporting documentation for:
a) procurement costs;
b) accident-related out-of-pocket medical expenses incurred; and
c) expenses and income information which demonstrates financial hardship
   (if the Medicare beneficiary is alleging financial hardship)
8.How long will it take for the waiver decision?
-Waiver cases must be processed within 120 days of receipt of the fully completed request (including a fully documented form 632-BK).
9.Is it necessary to write separate checks to all the Medicare contractors involved?
-No, you only need to issue one check and Medicare will notify the other Medicare contractors and make appropriate allocations.
10.Who do I make the check payable to and where do I send it?
-Make the check payable to the "Medicare Trust Fund" and mail it to the Medicare contractor processing the case (i.e. the lead contractor).
11.What do I do when my client believes Medicare claims included in the repayment settlement are not related to the accident/injury giving rise to Medicare's claim?
-Notify the lead contractor and submit documentation (e.g. medical records, a letter from the attending physician stating the services were not related to the injury, etc.). The contractor will review your request and make a determination based upon the available documentation.
12.Why is documentation needed to have unrelated claims removed from Medicare's claims list?
-Medicare cannot make a fully informed decision unless complete and accurate information is submitted. Medicare retains the necessary documentation to provide an audit trail and ensure quality controls are met.
13.Will my client's Medicare coverage be affected in anyway?
-Once the case has been settled and Medicare has been refunded its claim amount, Medicare will pay as primary payer on accident-related claims with dates of services (DOS) after the date of settlement. Medicare is NOT the primary payer for accident-related claims with DOS prior to the settlement date, even if the claims are submitted to Medicare after the date of settlement.
14.What is Medicare's Tax ID number?
-#52-1385894
15.How long does Medicare have to recoup money from my client?
-Under the statute of limitations (28 U.S.C. 2415), Medicare has six (6) years and three (3) months to recover Medicare's claim. The statute of limitations begins at the time Medicare is made aware that the overpayment exists.
16.Can I request an appeal if I am not satisfied with a waiver decision?
-Once a waiver decision is reached, you may, within 60 days of the date of the waiver decision, request a reconsideration of the waiver decision. In this instance someone new will review the case. If you are still not satisfied, you may request an appeal and have an administrative law judge (located offsite) review your appeal. You only have 60 days after the date of the decision to request an appeal.
17.Will Medicare reduce its claim further after the procurement process has been completed?
-The only other reduction after the procurement process is through the waiver process discussed above.
18.I have already settled the case and disbursed funds and now I learn from Medicare that I need to reimburse Medicare for claims. What am I suppose to do now?
-Because you are required to notify Medicare prior to settlement, you should supply Medicare with the settlement information and contact your client to inform him/her that Medicare should have been reimbursed. Medicare will send notification to you and your client that Medicare must be reimbursed with the funds received in the settlement. Medicare will research all claims paid related to the accident/injury, reduce its claim by the attorney's costs and fees, and inform the person with Medicare of the repayment amount. If needed, Medicare will set up an installment payment plan for the person with Medicare to relieve some of the burden of repaying Medicare.
19.What do I do when the settlement amount does not cover Medicare's repayment request?
-You must request a waiver in writing. (see question number 6)
20.I need a total claim amount from Medicare. How long will this take since I am ready to settle or go to trial?
-The lead contractor is responsible for obtaining paid-claim information from all Medicare contractors that made payments for accident-related services. Requests for claim information should be submitted as soon as possible, as it may take 6 to 12 weeks to obtain Medicare's total claim amount. Some claim information can be obtained from the Medicare beneficiary's Explanation of Benefits and the hospital/provider/physician who rendered the services. However, we advise that you wait for Medicare's official notice before settling a case, to ensure that Medicare's claim is fully taken into account. Section 1862(b) of the Social Security Act grants Medicare a priority right of recovery, and also gives Medicare the right of subrogation.


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