Medicare and Workers' Compensation Conflict

The Medicare Secondary Payer Act continues to complicate the workers' compensation process. Essentially, the Act requires that any treatment for a workers' compensation injury or disease be provided and paid for by the WC payer, with Medicare serving as a "secondary payer"...hence the name of the Act. With the status of Medicare's funding, the Act makes perfect sense from a philosophical basis. It was thought that for a WC claim, such as a broken arm, the care to bring the arm back to health and any residual treatment would be provided by the WC payer, prohibiting a practice that had in some cases existed for years where the WC claim was settled with the injured/recovering worker and follow up medical care was provided by Medicare. In such a simple instance, most payers would handle the broken arm claim to conclusion, with no implications to Medicare. But this requires that Medicare know and track all WC claims, down to the body parts and treatments accepted under the WC claim. Jurisdictions differ, each state has its own requirements for the length and type of care provided to the worker, and when that obligation has been fulfilled and responsibility discharged, including in many jurisdictions the ability of the two parties to settle the claim including future medical care costs. All WC claims where medical treatment is provided must be reported to Medicare. The detail required in the reporting should give Medicare sufficient information to determine if and when the WC payer has Ongoing Responsibility for Medical. And importantly, when they do not, which should automatically turn on the Medicare system for the beneficiary.

Unfortunately, Medicare's contractors (the government employees don't do the work, it is contracted out) are not able or willing to track the specifics of the WC claims. When Medicare feels that it is a secondary payer, any medical treatment claims to Medicare are denied, leaving the beneficiary to attempt to determine why the claim was rejected, deflect direct collection efforts of the medical provider and describe the status of their WC claim to Medicare in an attempt to remove the denial status. We have seen many examples of beneficiary claims denied because of the existence of a WC claim. The beneficiaries are understandably anxious, confused and angry. Bills are denied for shoulder treatment despite the fact that the WC claim was for an ankle. Low back treatment is denied when the WC claim was for a cut on the forehead. The examples are plentiful. Another example was published here today...

Hopefully Medicare's contractors can become more sophisticated and honor claims of the residents of the United States in a more timely, hassle-free process.