1. Report the case. You should report a client’s pending case to Medicare as soon as you can. Don’t wait until the case is at or near settlement. Waiting will delay the lien information that you need to make distributions to your client of settlement proceeds and may cause the defendant to name Medicare as a payee on the settlement check.

You can use a letter or you can report the information by telephone to 1-800-999-1118 Monday through Friday from 5:00 a.m. to 5:00 p.m. Pacific time. Reporting by telephone is fast but leaves no paper trail. It is a quick check to determine whether your client has been a Medicare beneficiary. The phone reporting is limited to three clients per call.

Your report of the pending case will be made to the Coordination of Benefits Contractor. All later correspondence will be with the Recovery Contractor assigned to your client’s claim by the Coordination of Benefits Contractor.

A specimen Reporting Letter is here.

2. Send Proof of Representation. Your report should include Proof of Representation so that Medicare can supply to you the same information Medicare sends to your client. You can submit your retainer agreement as Proof of Representation. It must be a fully-executed copy and you should write the client’s name and Health Insurance Claim Number at the top of the retainer agreement. If you prefer not to send you Retainer Agreement, then you can create a form.

A specimen Proof of Representation is here.

3. Receive a Rights and Responsibilities Letter. That Recovery Contractor will respond to your report by sending you a “Rights and Responsibilities” Letter.

A specimen Rights and Responsibilities Letter is here.

4. Receive a Correspondence Cover Letter. With the Rights and Responsibilities Letter will come a Correspondence Cover Letter.

A specimen Correspondence Cover Letter is here.

You should copy that letter and use it whenever you are writing to Recovery Contractor. You will also receive a brochure and Privacy Act notice.

5. Receive a Conditional Payment Letter. Within 65 days after your Rights and Responsibilities Letter is issued, you will receive a Conditional Payment Letter with an interim amount due to Medicare. You do not need to request the Conditional Payment Letter. Issuance of the Conditional Payment Letter is automatic and is triggered by your initial report and the subsequent Rights and Responsibilities Letter.

A specimen Conditional Payment Letter is here.

You should not pay the amount in the Conditional Payment Letter because the amount is interim. Every 90 days, Medicare updates the amount in that letter. Your client can see the amounts and the updates at MyMedicare.gov. As attorney, you will not have access to that site, except through your client. You should review the Conditional Payment Letter to be sure that the letter only includes Medicare payments relating to your client’s injuries.

6. Report the settlement. Report the settlement to the Recovery Contractor using the Final Settlement Detail Document.

A Final Settlement Detail Document is here.

7. Receive a Final Demand Letter. The Final Demand Letter requests payment, which you should send within 60 days to avoid interest.

A specimen Final Demand Letter is here.

When Medicare is named as a payee on a check, all other payees must endorse the check. The check is then sent to the Medicare Secondary Payer Recovery Contractor for deposit. The address is:

MSPRC – NGHP
P.O. Box 138832
Oklahoma City, OK 73113

The Medicare Secondary Payer Recovery Contractor will distribute any excess funds it has collected over and above the lien of Medicare.

The best procedure to avoid having Medicare named as a payee is to include the payee provision in the settlement agreement or release. Defendants and their insurers have no financial liability for the unpaid liens.

Where the beneficiary’s treating physician certifies in writing that treatment for the alleged injury related to the liability insurance (including self-insurance) “settlement” has been completed as of the date of the “settlement”, and that future medical items and/or services for that injury will not be required, Medicare considers its interest, with respect to future medicals for that particular “settlement”, satisfied. If the beneficiary receives additional “settlements” related to the underlying injury or illness, he/she must obtain a separate physician certification for those additional “settlements.”
When the treating physician makes such a certification, there is no need for the beneficiary to submit the certification or a proposed LMSA amount for review. CMS will not provide the settling parties with confirmation that Medicare’s interest with respect to future medicals for that “settlement” has been satisfied. Instead, the beneficiary and/or their representative are encouraged to maintain the physician’s certification.

The MSPRC is adding a Self-Service Information feature to its Customer Service Line. This new feature gives callers the ability to get the most up-to-date Demand and Conditional Payment amounts as well as the dates those letters were issued without having to speak with a Customer Service Representative. Some additional benefits include:
Extended Calling Hours – This new feature is available 24 hours a day, 7 days a week. Callers can now get case information outside of the MSPRC Hours of Operation.

No Wait Time – With the Self-Service Information Feature, there is no wait time to get case information. Callers no longer have to experience the wait time associated with speaking to a Customer Service Representative.

Unlimited number of cases inquiries on one phone call – Callers involved with multiple recovery cases can request information on additional cases with the same call.
Callers will need the following information to utilize the Self-Service Feature:
- Case identification number (found on all MSPRC correspondence)
- Beneficiary’s date of birth
- First five letters of the Beneficiary’s last name as it appears on their Medicare card
- Last 4 digits of Beneficiary’s Social Security number (or full Medicare number)
The Self-Service Feature goes live on September 30, 2011.

Medicare has implemented a $300 threshold for certain Liability Insurance cases. If all of Medicare’s criteria are met, the MSPRC will not recover against the beneficiary’s settlement, judgment, award or other payment.
If you’re a beneficiary, what does this mean for you?

As of September 6, 2011, if you’ve received a lump sum settlement of $300 or less, and your case meets certain conditions, Medicare will not recover from that settlement. These conditions include:

1. Your settlement is related to an alleged physical trauma-based incident, not an alleged exposure, ingestion, or implantation, and
2. You do not have any additional settlements related to the same alleged incident.

Please note that this threshold specifically excludes settlements where an insurer is paying your medicals bills directly or on an ongoing basis. This threshold also does not apply if a demand letter was already issued for your case.

The Centers for Medicare & Medicaid Services will be implementing a new and simple fixed percentage option that will be available to certain beneficiaries beginning November 7, 2011. This option is available to beneficiaries who receive certain types of liability insurance (including self-insurance) settlements of $5000 or less. A beneficiary who elects this option will be able to resolve Medicare’s recovery claim by paying Medicare 25% of his/her total liability insurance settlement instead of using the traditional recovery process. This means that a beneficiary will know what he/she owes and will be able to immediately pay Medicare.

In order to elect this option, the following criteria must be met:
1. The liability insurance (including self-insurance) settlement is for a physical trauma based injury. (This means that it does not relate to ingestion, exposure, or medical implant), and
2. The total liability settlement, judgment, award, or other payment is $5000 or less, and
3. The beneficiary elects the option within the required timeframe and Medicare has not issued a demand letter or other request for reimbursement related to the incident, and
4. The beneficiary has not received and does not expect to receive any other settlements, judgments, awards, or other payments related to the incident.

A full explanation, including instructions on how and when to elect this option, will be available November 7, 2011 at http://www.msprc.info/.

Please Note: When a beneficiary elects this option, he/she must understand that as part of choosing the option he/she will be giving up the right to appeal the fixed payment amount or request a waiver of recovery for the fixed payment amount.