Medicare Secondary Payer (MSP) Tips

Risk Managers, Claim Managers, Adjusters and Attorneys are all obligated to inform the injured Medicare Beneficiary about consideration of MSP rules and compliance during the claim settlement process.   What are the key considerations for these obligations in the discovery process? 

MSP rules apply to all parties in the settlement of a Liability, Workers Compensation and/or No-Fault claim for a Medicare Beneficiary.  Careful drafting of the MSP language in the settlement agreement to address the issues of a particular case are important for compliance.  Key considerations to accelerate the settlement of this type of claim include:

• “Body part” identification for the accepted injuries, along with correlated International Classification of Diseases (ICD) codes need to be well understood by all parties as soon as possible in the investigative process. If the claim has progressed to a legal status, the representative attorneys should come to an agreement as soon as possible about the claimed injuries.
• Before an insurer or self-insurer (or their Third-Party Adjustment (TPA) advisors) reports a claim under Medicare Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA) of 2007, there should be a clear understanding of the accepted injuries of the case. Support may come from the primary treating physicians or independent medical examiners. It is vitally important to be sure exactly what codes should be reported to make sure Medicare includes only accident-related injuries in their conditional payments and Medicare Set Aside (MSA).   
• When all parties review the current Medicare Conditional Payment reimbursement obligations, there should be an agreement between the parties about what is related to the case so that proper settlement negotiations may occur. Any unrelated conditional payments should be disputed as soon as possible to avoid further confusion and liability.
• If the Beneficiary is still treating for their injuries, a Medicare Set Aside will address any future obligations to Medicare. Funding and payment of future treatments may also be negotiated at that time.

An understanding of these factors will save time and resources to settle a claim.  Additionally, the documentation will provide support for any compliance investigation for the settlement.  If you are interested in learning more about our products and services to support Accelerated Claim Settlement Solution initiatives, please contact Robert J. Blackburn at This email address is being protected from spambots. You need JavaScript enabled to view it. or 585-586-4530.

By Robert J. Blackburn, Managing Principal, Blackburn Group, Inc., contact him at This email address is being protected from spambots. You need JavaScript enabled to view it..