As a Responsible Reporting Entity (RRE), it’s not an option to inaccurately or incompletely report Medicare-related settlement claims under Section 111 requirements. It also doesn’t make sense to report them properly, then fail to submit payment to Medicare. In both cases, the penalties are too steep to justify any sort of negligence.
However, that doesn’t mean Medicare should get any more than it’s rightfully owed.
Vet every claim
After a claim is properly reported via Section 111 requirements, a RRE must request a Conditional Payment Letter (CPL) from Medicare. The CPL itemizes the health care charges Medicare has paid on behalf of the Medicare beneficiary. P&C insurers are then required to reimburse Medicare for legitimate Conditional Payments made on behalf of the beneficiary.
However, nearly half of these CPLs contain items that are unrelated to the accident or injury and should not be included on the reimbursement request.
How does this happen?
Imagine this simplified scenario:
Uncle John has a slip-and-fall accident at the supermarket and is hospitalized with a broken hip. During the days he is admitted to the hospital, he receives several different procedures and medicines, and benefits from the services of three different specialists. Also, while he’s there, the hospital provides a daily insulin shot (for diabetes) and a blood thinner (prescribed for high blood pressure), both of which Uncle John has been taking for years.
Months later, when Uncle John is back on his feet and the case is settled, Medicare is notified and they gather together the medical bills they paid on John’s behalf back when he was in the hospital and immediately following. They know he was admitted for a broken hip, which is the same injury the liability claim revolves around, so they compile those bills and present them in their CPL.
However, a detailed review of the claim, the medical bills, and the CPL will reveal that the charges for Uncle John’s daily insulin shots and blood thinner were required in treatment of a pre-existing condition, and therefore should not be lumped in with the legitimate medical bills involved with the broken hip.
Those charges should be disputed, and the overall reimbursement amount demanded by Medicare should be lower as a result.
Why professional help is vital
As noted, this scenario is heavily simplified. In reality, locating and successfully disputing these line items to ensure that you’re not overpaying Medicare is a time-consuming and difficult process.
Claims adjusters are generally not trained to quickly and efficiently monitor Medicare claims. In many cases, claims adjusters are quick to write a check and pay Medicare whatever they ask for in order to cut down on cycle times. Of course, this increases costs in the end because they’re paying Medicare more than they should.
The best option for every P&C insurer is to entrust their Medicare reporting and recovery process to professionals who handle these claims all day every day. At Flagship Services Group, we offer a suite of services that can carry your Medicare claims from start to finish – including that all important claim-vetting step we discussed above – quickly and efficiently.
Learn more about saving money on Medicare reimbursements by downloading the free white paper below.
Photo Credit: Jenny Huey via Flickr