Medicare Claim - Nursing Home Case

Posted by Mary Skinner

Question:
We settled a case for a client and got a final demand for Medicare as well as for Anthem. We paid those. The nursing home bills Medicare and Anthem in 6 month intervals. These liens were calculated (and the case settled) in between one of these intervals, so it is likely that when the nursing home bills Medicare again, some of the bill will related to services rendered prior to the settlement, but just not included on the lien statement that was paid (final demand).

So, the question is what should I tell my client? Will Medicare come back after the final demand is paid?

-Ohio Attorney

Answer:
Medicare is under no obligation to pay primary for any injury related care that occurred prior to settlement, even if the claims are submitted to Medicare after settlement. With that said, it is possible that Medicare will deny payment. Additionally, Medicare only pays for the first 100 days of nursing home care, unless the beneficiary is admitted to the hospital for at least 3 days. Once the beneficiary returns to the nursing home, the 100 day clock starts all over.