Although Medicare cannot pay for services or items paid under a workers' compensation law or plan, Medicare may make a conditional payment - to avoid imposing a hardship on its beneficiaries - if there is a long delay between the occurrence of an injury and a decision about reimbursement by the state workers' compensation agency. Medicare retains the right to recover a conditional payment made while awaiting the state agency decision.
If the claim is contested, pending the workers' compensation agency decision, a claim may be filed with Medicare, along with a copy of the workers' compensation carrier's explanation of benefits, for conditional payment. With the claim, a statement should be included indicating that the claim is being contested and providing the:
- Name of the insurance company,
- Name of the person or company with insurance,
- Claim number,
- Name of the employer,
- Employer identification number, and
- Employer location.
Medicare will remain primary payer for services not related to the work injury or illness. Medicare will make secondary payment when covered services are not fully reimbursed under the workers' compensation plan and when the physician is not bound to accept the workers' compensation payment as payment in full.
Medicare cannot make payment for beneficiaries who state they are not requesting payment under workers' compensation for expenses incurred in connection with an on-the-job injury because they do not wish to report the injury to their employer.
Medicare will make no payment if the workers' compensation carrier has paid an amount that:
Equals or exceeds the Medicare allowable charge;
- Equals or exceeds the physician's charge(s) for Medicare covered services; or
- The physician accepts or is required under the workers' compensation law to accept as payment.
Source: TrailBlazer Medicare Secondary Payer Manual
TMA Practice E-tips main page