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Compliance

Medicare is Issuing Denials

The Centers for Medicare and Medicaid Services (CMS) asserts it has the right to deny paying for a treatment if a settlement recipient still has funds in a Medicare Set Aside (MSA) or has not properly reported their full exhaustion of those funds.  Some attorneys, adjusters and injured parties have questioned over the years - is Medicare really denying bills? The truth is that Medicare is issuing denials.

Below is an image of a true denial letter from CMS. The following document is a Medicare Summary Notice sent to a Medicare beneficiary. On page 2, you can see that a service was not approved, and looking at footnote E, CMS explains:

“Your claim has been denied by Medicare because you may have funds set aside from your settlement to pay for your future medical expenses and prescription drug treatment related to your injury(ies).”

In this instance, a man settled his case in 2014, without a professional administrator. Unfortunately, he did not spend his MSA funds in accordance with CMS guidelines. He was receiving denial letters from Medicare, and they were not paying for treatment, so he reached out to us asking for help.

This document shows that CMS is becoming savvier and denying treatments that should be paid for with settlement funds. Injured parties that do not expend their settlement funds appropriately are at risk of jeopardizing their future Medicare benefits.

Do you have questions about Medicare compliance? Reach out to us!

2 Comments Posted on This Article:

  • The claimant received a denial from Medicare… did the claimant eventually get back on track with CMS to get his future medical paid? What does that process look like?

    • Thanks for your question, Monica. Yes, we were able to assist this individual with ensuring that Medicare paid for treatment. When MSA funds have been properly exhausted, Medicare will step in and pay as primary. This is the case whether the fund has been permanently exhausted or if there has been a temporary depletion pending annual funding via annuity. However, when Medicare believes there are still funds available in the MSA account, they will deny bills related to treatment for the underlying injury which are otherwise covered by Medicare. Attestation is the required reporting to Medicare to alert them of, among other administration details, exhaustion or depletion. In some instances there can be a disconnect with regard to the information Medicare has and they can mistakenly deny payment. In general, as in the instant case, the situation can be resolved by proactively connecting with Medicare and ensuring they have the correct information. This is why attestation is so critical and why we advocate for electronic attestation – which will mitigate against a potential disconnect / discrepancy.

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