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Key Components of Medicare Compliance

By Natalie Sterling


Medicare Compliance Overview

Medicare compliance is critical to ensuring that legal practices involving Medicare-related matters adhere to relevant rules and regulations. Concerns about Medicare compliance generally arise in cases involving personal injury, worker’s compensation, or other types of settlements in which Medicare may have a secondary payment responsibility for medical expenses. Attorneys must be aware of the legal requirements in these cases to avoid liability and penalties.



Key Components of Medicare Compliance for Attorneys


1. Medicare Secondary Payer (MSP) Rules

The Medicare Secondary Payer (MSP) statute is designed to prevent Medicare from paying for medical expenses when another payer, such as an insurance company or a liable third party, is responsible. Attorneys must ensure that Medicare’s interests are protected in settlements by ensuring Medicare payments made for care related to the claim are reimbursed.



2. Conditional Payments

When an individual receives a settlement and Medicare has made payments for care related to the claim, those payments are considered "conditional payments" that must be reimbursed. Attorneys must:

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  • Request a Conditional Payment Letter from Medicare to identify payments made by Medicare on behalf of the injured party.

  • Audit for any unrelated charges and file a dispute with Medicare to have those unrelated charges removed.

  • Ensure those payments are accounted for and included in any settlement amounts.

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3. Reporting Requirements (Section 111 of the MMSEA)

Under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA), attorneys and insurers must report settlements to the Centers for Medicare & Medicaid Services (CMS) if Medicare could potentially have an interest. Attorneys must:


  • Report settlement information for certain claims to CMS to avoid penalties.

  • Make sure the reporting is timely and accurate to prevent issues with Medicare’s reimbursement.

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4. Best Practices for Attorneys

Attorneys handling Medicare-related cases should:

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  • To ensure proper compliance, consult a Medicare expert (e.g., a Medicare compliance consultant or MSA professional).


  • Maintain thorough records of all Medicare-related communications, payments, and settlements.


  • Be proactive in requesting Medicare’s reimbursement demands early to avoid delays.


  • Stay updated on changes in Medicare compliance regulations, as they can shift frequently.



Conclusion

In summary, Medicare compliance requires careful attention to the interplay between Medicare, other insurers, and the injured party. Attorneys must protect Medicare’s interests, avoid potential penalties, and facilitate proper reimbursement for conditional payments.



About the Author

Natalie Sterling is the Program & Business Development Director for Compass Lien Resolution. Over the last 10 years, Natalie has helped hundreds of law firms navigate the complicated Medicare landscape to ensure that claims are processed accurately.

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