Friday, August 3, 2007

Medicare Compromise

Posted by Mary Skinner, Matthew Garretson

Matthew - You have been very helpful in your posts about Medicare, and I wonder if I might ask your input on a matter I am handling. I have a case with serious injuries and serious liability problems. I have a firm offer and want to ask Medicare to compromise. I don't think a full waiver is likely (the offer is $500K and the Medicare payments are about $148K). What is the process for asking for compromise (i.e., whom do I contact and what information do they need?)? Also, are they doing anything at this point in auto cases on future set asides? I have heard they really are only doing them in [workers compensation] at this point. My [client] has no plans for future care at this point, and it seems doctors have done what they can. Thanks for any pointers or info you can provide.

-Minnesota Attorney

In those situations where a beneficiary has received a firm binding settlement offer, Medicare may enter into pre-settlement discussions regarding compromise of Medicare's claim against that firm binding settlement offer. A beneficiary has no further appeal rights if CMS and the beneficiary agree to a compromise. Mary Skinner, our manager of Medicare services may be able to provide you with information regarding the forms and contact info for requesting compromise.

With respect to set asides, you are correct; they are generally only required in WC settings. It is a very rare fact pattern wherein I would suggest a set aside for a liability case. You can find further detail in an article I recently published, Medicare’s Reimbursement Claim — The Only Constant Is Change. Hope this info helps.

-Matt Garretson

All pre-settlement compromise requests must be in writing and sent to the MSPRC (Medicare Contractor), they will forward your request to the CMS Regional office. However, due to the backlog that the MSPRC is currently in, I recommend that you also send your request directly to the Regional Office for the state that your client lives in. I will provide you with the address of the regional office where you need to send the request if you provide me with the state that your client resides in.

When submitting your request, craft a compelling story. Provide them with the facts of the case, the injuries your client sustained, the effect the injuries have had on your client financially (out of pocket expenses, such as non-covered medicals, home renovations, etc.) and their quality of life prior to the injury and after. Also, advise them what your client would use the settlement proceeds for should they compromise their lien. Medicare believes strongly in equity for equity, so if you were to reduce your fee or absorb some of the case expenses Medicare would look more favorably on your compromise request. If possible, provide any evidentiary documentation to support your request. Should you have any questions regarding the above information please contact me.

-Mary Skinner