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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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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