Serving Chiropractors and Their Patients

Recent WI Court Decision Addresses Medicare Claims Submission

A Court decision was recently rendered in Wisconsin which addresses the intracacies of claims submission to medicare in situations involving treatment of patients involved in “tort” or negligence cases where there is a third party- insurer  available to pay for treatment expenses.  That third party can commonly be a workers compensation insurer of the patient’s employer or liablity insurer of  a negligent driver involved in an accident with the doctor’s patient. In the case of Conrad Laska v. General Casualty Company, the Wisconsin Appellate court noted several important medicare reimbursment concepts in these types of situations.  In this case, a hospital filed a statutory lien against a tort or third party payor seeking payment out of any eventual settlement or jury verdict, rather than billing medicare for an injured parties treatment.  The Court reviewed several medicare reimbursement concepts in its decision which are worthy of consideration by the chiropractor treating patients involved in these situations.

First, the Court reviewed the “Provider Agreement Statute” (42 USC 1395cc-Special “legal speak” for the United States Code)  Under this statute, a provider participating in the medicare program “may not charge any individual or any person for…services for which such individual is entitled to payment under medicare.”  Doctors should always consider the wishes of patients involved in these tort claims as to whether they prefer to utilize their medicare coverage for the treatment since no further recovery can be sought from the patient if reimbursement is obtained from medicare.

Second, the Court noted the “Secondary Payor Statute” (42 USC 1395yb)  Under this statute, medicare is a secondary payor (to the negligent party’s tort or liability insurer; who is the “first party payor”) for medical services provided to a medicare eligible patient when “payment has been made or can reasonably be expected to be make promptly under a worker’s compensation policy or under an automobile or liability policy.”  Promptly has been defined by regulations as within 120 days after the earlier of (1) the date the claim is filed with an insurer or (2) the date the service is furnished.  Also, a provider must submit bills to medicare within one year of the date of service.  42 CFR s. 424.44(a).  As most doctors find when billing a worker’s compensation insurer of the negligent driver’s insurer for patient care, it is very unlikely that reimbursement will be paid “promptly” within the 120 day  period.  As a result, most doctors avoid the risk of no reimbursemt or uncertainly of waitng for settlement or jury verdict by resorting to billing medicare within the one year of care time limitation.

Finally, the Court commented on those situations where the doctor takes on the “risk” of not promptly billing  medicare, but instead resorts to waiting for reimbursement from the negligent party’s insurer.  The Appellate Court commented on a  2000 memorandum from the Department of Health and Social Services which states that a “provider of services are required to drop their liens (for payment) and terminate their billing efforts to collect from a liability insurer or a (medicare) beneficiary  once the medicare billing period expires (one year from date of service) unless the liability claim was settled prior to the expiration of the medicare billing period.  Since many personal injury claims take longer that a year from the date of chiropractic service to finally resove, the doctor may ultimatly be  left with no recourse for recovery from either the negligent party’s insurer or the medicare patient.

These are three very important concepts which should be kept in mind when  treating medicare patients who have claims against negligent party’s offering third party liablity coverage.  The doctor usually has the choice of either billing medicare within one year of treatment if that negligent party’s insurer does not promptly (120 days of care) provide reimbursement or continue to pusue recovery exclusively against a liablity insurer  since medicare (and  certainly not the medicare patient) cannot be billed outside of that one year period.  The option taken by the doctor must be carefully reviewed and approved by the medicare patient so as to prevent situations where the patient refutes any obligation for payment when the doctor has troubles ultimatley recovering from the tort or liablity insurer.