Medicare as a Secondary Payer - Liability Situations

MEDICARE AS SECONDARY PAYER (MSP) - LIABILITY SITUATIONS

WPS Medicare understands that there can be confusion in the provider community about billing Medicare or a liability insurer. Providers also are unsure of what amounts they can collect from the patient when a liability situation exits.

If a provider is aware that a liability situation exists, the provider should bill the liability insurer first within a 120-day "promptly paid" period. If the liability insurer does not make payment within this timeframe, the provider has a decision to make. The provider can bill Medicare or pursue the liability claim.

A provider choosing to bill Medicare would bill the charges as usual. Providers not accepting assignment can collect amounts up to the Limiting Charge. Providers accepting assignment can collect deductibles and coinsurance amounts. The provider cannot pursue a lien or claim against the liability insurer or the beneficiary for amounts collected from the liability insurer.

A provider choosing to pursue the liability claim should be aware that they cannot collect any amounts from the patient until the liability claim is completed. Once the liability claim is completed, the provider can collect actual charges up to the amount of the liability claim.

Medicare's timely file limit still applies. Therefore, if the provider pursues the liability claim and there is no payment by the liability insurer, the provider may not collect any amounts from the patient once the timely file limit has expired.

Continued pursuit of collection of the payment of actual charges from the proceeds of the liability insurance after the provider has billed Medicare violates the provider agreement. CMS

(Centers for Medicare & Medicaid Services) currently has inaccurate information in the Internet Only Manual pertaining to this issue and they are updating the section in question.


To read more about Medicare updates including Billing Health Insurance Information check out Medicare Medical Coding and Billing Courses

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