Conditional Payment Services

//Conditional Payment Services
Conditional Payment Services2017-08-10T13:46:57+00:00

At CompEx MSA, 15 years of experience have trained our professional account administrators to understand the complex rules surrounding the health care needs of injured Medicare and Medicaid recipients. That’s why we track every case through each of its different courses, including when Medicare or Medicaid have made payments to health care providers for services offered to a Medicare or Medicaid recipient that are the responsibility of an employer or another insurance carrier.

Medicare Conditional Payments

Pursuant to the Medicare Secondary Payer law (42 U.S.C. § 1395y(b)), when Medicare makes these conditional payments to health care providers, it has the right to be reimbursed for those expenses. Assessing, itemizing, and reporting those expenses is mandatory practice for all employers and insurers who assist injured Medicare recipients when they are injured on the job, or by a third party.

Within the underlying case, Medicare’s reimbursement interest is registered as a lien against the final resolution of the case and that value will be dispersed to CMS before any other funds are released from the settlement proceeds. Resolution of the lien means communicating about rights and obligations related to the lien with all parties of the case who have an interest in the final settlement, including CMS, the Coordination of Benefits Contractor, the Medicare Secondary Payor Contractor, and, especially, the injured party’s attorney.

Medicaid Conditional Payments

Unlike Medicare, Medicaid is, by law, the “payer of last resort,” which means that any other party legally responsible for health care costs of injured workers must pay the full complement of their obligation before Medicaid can be compelled to contribute funds to the case. Medicaid provides coverage to specified populations – the elderly, pregnant women, disabled people of any age, the blind, and children with no other health care coverage. Each category of Medicaid applicants has a different set of qualifying requirements that must be satisfied to receive Medicaid benefits. Sometimes injured workers (or those injured through the negligence of another) are ‘dual eligible’ to receive health care payments from both Medicaid and Medicaid while their liability case is pending.

In the case of the dual-eligible WC or negligence injured plaintiff, both Medicare and Medicaid will obtain liens against the final settlement sum of the case to the extent that they have each provided health care payments contingent on reimbursement.

Resolving the Medicare or Medicaid Lien

At CompEx, we pride ourselves on our comprehensive Medicare and Medicaid lien resolution services.

Lien Verification

Resolving either or both a Medicare or Medicaid lien begins by ensuring that the liens have been filed accurately within the WC case, and that the charges listed on those documents are accurate to the case.

To ensure each lien is verified, CompEx routinely performs the following services:

  • Reporting the File to Medicare/Medicaid;

  • Checking the record for the existence of a valid Medicare or Medicaid lien and seeking Agency documentation on the value of their lien;

  • Review of detailed charges and removal of unauthorized or erroneous charges;

  • Maintaining the file for three months, with Monthly Updates to our Clients.

Lien Resolution

Once the validity and value of the lien is confirmed, CompEx will negotiate with the lien holder for a reduction in its value, when appropriate, to ensure that our clients are exposed to the lowest costs possible when finally resolving the case.

At CompEx MSA, we take on that practice on behalf of our nation-wide roster of clients:

  • We notify and verify for Medicare and Medicaid when primary payers are identified;

  • When necessary, we also notify Social Security if a claimant may be eligible for SS support;

  • We will analyze conditional payment documents to verify their accuracy;

  • We will review case documents, including medical records and settlement documents, to ensure the rights of Medicare and Medicaid are protected and the claimant and their employer or insurer are in compliance with applicable laws, and
  • In the event there are outstanding liens in the case at its termination, CompEx MSA will work to resolve those so the case can be closed altogether.

At CompEx MSA, we ensure that no employer or insurer overpays Medicare or Medicaid for conditional payments made while the case was ongoing.