The unique and evolving constellation of symptoms and conditions caused by the virus are not just confusing medical personnel, however. Legally, there are new challenges presented by the virus that have never before been seen by the WC and legal systems. As cases flowing from these issues mature and claimants seek support as they recover, their claims will most likely change how work-related COVID cases - and cases originating from the pandemic itself - are managed in the legal setting.
Medicare and the Workers’ Comp System
The Medicare and Medicaid systems are fundamental sources for healthcare services for America's seniors and disabled people. The Centers for Medicare and Medicaid Services (CMS) runs the healthcare networks that span the country and provide medical services for millions of people. When Medicare-eligible people suffer injuries at work, CMS can only provide healthcare funding when there is no other entity who is or should be held liable for those costs. It is this circumstance - the nexus of the CMS and Workers’ Compensation (WC) systems - where numerous issues and concerns arise in many, many injured worker cases.
The Medicare Set-Aside Account & WC Case
In a straight-up WC case, the actual cause of the accident may not be significant to the case's final resolution (that's what the insurance is for). In the WC/Medicare cases, however, causal factors may matter a lot.
Under the Medicare Secondary Payor Act (MSP), Medicare funds are deemed 'secondary' (to be used after primary funds are exhausted) to those of other, non-employer entities if they contributed to the cause of the injury. However, that 'secondary' classification can't be made until those contributing factors are established, and that determination may not be made for days or even months after the incident. The MSP Act asserts that when another entity is deemed to have caused the injury, then it is improper to use Medicare funds to cover the cost of the recovery. Further, when that determination is made, but Medicare funds are already dispensed, then the CMS has a legal duty to go after that other entity to retrieve those funds back.
Introduction to Workers’ Compensation and Medicare
Review the basics of Medicare & WC via this course.