Payment Matters

January 24, 2013

Changes to Medicare Secondary Payer Conditional Payment Rules

By: Christopher P. Dean

Health care providers routinely treat Medicare beneficiaries who are injured from an accident or an employment injury. If another payment source like a personal injury no fault policy, workers’ compensation insurance policy, or other funds are available, then Medicare is the secondary payer. Although providers are generally required to bill other payers first, in some circumstances the provider can bill Medicare conditionally for the treatment. When Medicare makes a conditional payment, the primary policy or provider must reimburse Medicare for the conditional Medicare payment once the primary payer pays. This often gives administrative headaches to beneficiaries and policy administrators alike as Medicare seeks reimbursement for the conditional payment as the secondary payer.

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AHA Survey Identifies Continuing Problems with Medicare RAC Program

By: Mark A. Stanley *

The American Hospital Association (AHA) published its RACTRAC Survey results for the third quarter of 2012. The AHA created the survey in response to the lack of information released by CMS on its Medicare RAC program. For the third quarter of 2012, the survey notes several problems with the Medicare RAC program, including a significant rate of claims that were erroneously disallowed, as well as many issues with administration of the RAC program. The report is likely to be relevant to the litigation currently being pursued by the AHA, which we discussed here.

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Court Rules That Medicare DSH Statute Means What It Says

By: Thomas W. Coons

In recent times, the provider community has enjoyed success in challenging the Secretary’s interpretation of the Medicare disproportionate share hospital (DSH) adjustment provisions and what, the providers have maintained, often was the impermissible retroactive application of those interpretations to past years’ claims. Not every DSH challenge, however, is successful, as a recent case out of the United States Court of Appeals for the Fifth Circuit illustrates.

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