Payment under Medicare may not be made for any item or service when payment has been made or can reasonably be expected to be made for such item or service under a workers' compensation (WC) law or plan of the United States or any state. If it is determined that Medicare has paid for items or services that can be or could have been paid for under WC, the Medicare payment constitutes an overpayment.
If payment for services cannot be made by a WC plan because they were furnished by a source not authorized by WC, Medicare can pay for such services.
The beneficiary is responsible for taking whatever action is necessary to obtain payment under WC where payment under that system can reasonably be expected (e.g., filing a claim in a timely manner, furnishing all necessary information). If failure to take proper and timely action results in a loss of WC benefits, Medicare benefits are not payable to the extent that payment could reasonably have been expected under WC.
If it is determined that the liability or no-fault insurer will not pay "promptly" (within 120 days), Medicare may make a conditional payment. However, when the proceeds from the no-fault or liability settlement become available, Medicare has priority right of recovery. Medicare may also make a conditional payment of a claim provided the beneficiary because of incapacity failed to file a proper claim.
If a provider/supplier chooses to bill Medicare after the 120-day period, they must withdraw claims against the insurer and any liens placed on the beneficiary’s settlement. If they choose to continue their claim against the insurance settlement, they may not also bill Medicare.
All workers’ compensation cases that involve a Medicare beneficiary must be reported to the COB Contractor. When calling to report a new case, please be sure to have the following information available:
Beneficiary’s Health Insurance Claim Number
Date of the accident/incident
Description of illness/injury
Name, address of the workers’ compensation insurance carrier
Name, address of the legal representative
Once this information is received, COB will apply it to your client’s Medicare record, assign the case to a Medicare contractor, and inform you and your client of the applicability of the MSP program and Medicare’s recovery rights. You will receive a notice advising you of the Medicare contractor assigned to handle the specifics of the case to recovery, Medicare’s right of recovery, and a beneficiary consent to release form. Once this process is completed, all further inquires must be made through the assigned Medicare contractor. Please note that Medicare's interest cannot be determined until the beneficiary’s record has been annotated with the specifics of the case.
Medicare regulations make a distinction between lump sum settlements that are commutations of future benefits and those that are due to a compromise between the workers' compensation carrier and the injured individual. The "Workers' Compensation: Commutation of Future Benefits" letter (in Adobe PDF) will answer some of the questions you may have regarding this policy.
If you would like to report a workers’ compensation case or have a general workers’ compensation question, please contact the COB Contractor by phone or mail. Customer Service Representatives are available to provide you with quality service Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays. The COB Contractor’s toll-free number is 1-800-999-1118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired. The mailing address for written inquiries is:
Medicare - Coordination of Benefits
P.O. Box 5041
New York, New York 10274-5041