Monday, January 19, 2009

Medicare Appeal

Posted by Mary Skinner

I’m contacting you in the hopes that you can provide us with some advice regarding an old file we have. Our firm has been in contact with Medicare for about five years trying to resolve Medicare’s lien for one of our clients who received a $40K settlement from Howmedica in 2004. On several occasions the firm requested waiver documents and even offered payment in June 2006, but Medicare would never provide a final lien amount. Fast forward to two years later and Medicare finally provided a lien amount with interest along with waiver forms. These forms were sent to our client and not to our firm. Our firm then forwarded our client’s completed waiver form to Medicare. Then in December 2008, our client received another letter from Medicare denying the waiver and providing the lien amount owed plus interest. While Medicare’s letter advises a copy was sent to our firm, we have never received a copy of the 12/11/08 letter. We obtained a copy from our client. It states that Medicare’s conditional payments were $18,998.65 and the procurement costs were $17,875.14. After allowing $8,490.09 as Medicare’s share of the procurement the amount due to Medicare is $10,508.56 plus interest – which is now $11,570.36. She was denied a waiver because her “circumstances do not fall within the criteria used to grant a waiver.” At this time, we are considering filing an appeal in an attempt to at least get the interest removed from the lien amount. Our question to you is whether you believe there is any chance of a successful appeal or should we just pay the lien in order to stop further interest from accruing? Thank you for any information you can provide.

-Florida Attorney

I’m happy to give you some insight. First and foremost, regardless of whether or not you file an appeal, make reimbursement to Medicare. Interest will accrue until Medicare is paid the principal and interest they are demanding. As for the appeal, you will need to provide additional documentation to support the reason for your original waiver request or documentation to support one of the other criteria for a waiver. The criteria for waivers are: out of pocket expenses, financial hardship and equity and good conscience. Based on the information you provided (settlement amount and the demand amount) it is an equitable split, therefore the criteria of equity and good conscience are no longer applicable. However, if there are circumstances where you could argue financial hardship or out of pocket expenses you may appeal the waiver. As for being successful in getting Medicare to waive the interest, you would need to prove that Medicare was at fault and the interest was accrued in error. With that said, Medicare’s demand letter is clear in stating that reimbursement must be made within 60 days of the issue date of the demand or interest will accrue regardless of whether or not a waiver is being requested.