MEDICARE COMPLIANCE
Welcome to Synergy’s blog page dedicated to the topic of Medicare compliance. Our team of Medicare experts share their InSights and knowledge on the latest developments and best practices for law firms to stay compliant with the MSP. Stay up-to-date with the latest trends and strategies to ensure that you have the information you need to navigate the complex world of Medicare compliance. Our blogs provide practical tips and advice for ensuring that your clients receive the medical care they need while complying with Medicare’s requirements. Let our experts guide you through the intricacies of Medicare compliance and help you stay on top of the latest developments in this rapidly-evolving field.
In the world of personal injury litigation, where settlements can make or break a client’s future well-being, coordination of benefits is no longer a side issue, it’s central to protecting your client’s recovery. For veterans, military retirees, and their families, that complexity multiplies when Medicare, TRICARE, or VA benefits overlap. Once you add a client’s injury recovery to the mix, personal injury firms must be careful to avoid compliance pitfalls, reimbursement demands, and potential denial of care.
So how do these benefit systems interact and why does it matter for your client?
The Basics:
TRICARE, TRICARE for Life, and benefits under the Department of Veterans Affairs (VA) provide essential health care coverage to military service members, veterans, and their families, but they serve different populations and have distinct features. TRICARE primarily offers health care to active-duty service members and their dependents under the age of 65. It provides a range of services including medical, dental, and mental health care through various plans like TRICARE Prime and TRICARE Select. In contrast, TRICARE for Life is a premium-free health care program specifically for Medicare-eligible military retirees and their dependents, which acts as a secondary payer to Medicare and enhances benefits by covering additional services not fully addressed by Medicare. On the other hand, benefits under the VA focus on providing comprehensive health care to veterans with a variety of services, including specialized care for service-connected injuries and conditions. While TRICARE emphasizes readiness and access for currently active military personnel, TRICARE for Life reinforces support for older veterans with Medicare coverage, and VA benefits cater primarily to those who have discharged from military service. Each program is tailored to meet the unique needs of its respective beneficiaries, highlighting the complexities of health care available to those who have served in the U.S. Armed Forces.
Who Pays First?
Understanding the payer hierarchy is critical. Medicare, Tricare, and the VA all have distinct rules about who pays when:
- TRICARE acts as a secondary payer to Medicare. If your client has both, Medicare pays first, and TRICARE picks up what’s left, as long as the service is covered under TRICARE.
- VA benefits, however, are not health insurance. The VA provides care for service-connected conditions, often outside the coordination rules that apply to Medicare or TRICARE.
- Medicare is always the primary payer when used with TRICARE, unless the medical condition is service-connected, in which case the VA may take priority.
When a PI settlement enters the equation, things get trickier. Now Medicare’s rights under the Medicare Secondary Payer Act (MSP) come into play, potentially triggering obligations, even if other programs are involved.
Why This Matters in the Personal Injury Context
When a veteran or military retiree is injured and receives a settlement, failing to coordinate correctly between these programs can lead to:
- Duplicate payment recovery demands from Medicare, VA, or TRICARE
- Denial of future Medicare-covered care
- Compromised client recoveries
- Malpractice exposure to the trial attorney
Even more critical, Medicare may conditionally pay for treatment related to the injury, expecting reimbursement once the settlement is finalized. But if TRICARE also pays or the VA is involved, lawyers must untangle the web of who owes what and when.
Practical Example
Let’s say your client is a 68-year-old military retiree with TRICARE and Medicare. They were injured in a motor vehicle accident and treated at a civilian hospital. Medicare pays first; TRICARE covers the balance. The VA is uninvolved unless the injury is tied to military service.
When a settlement is reached, Medicare will seek reimbursement for conditional payments made for injury-related care. But here’s the catch: if TRICARE also paid, there may be a duplicate demand, or worse, a confusing mismatch in what each program believes is owed.
Without a coordinated lien resolution process, your client could be stuck repaying more than required or face future coverage denials.
What About VA?
If care was rendered at a VA facility for a service-connected condition, VA is usually primary, and Medicare/TRICARE may not be involved. But if the injury is not service-connected, Medicare steps in, and the VA may bill the client directly.
The VA also asserts its own lien rights under 38 U.S.C. § 1729, meaning it may demand reimbursement from the PI settlement. These claims are governed by different rules than Medicare and must be negotiated separately—something many lien resolution vendors miss.
Why This is Important to Trial Lawyers
Ignoring or making mistakes regarding these coordination rules can:
- Jeopardize the client’s future care
- Delay disbursement of settlement funds
- Invite government recovery actions
- Create financial exposure for your firm
Worse, failure to account for the VA, TRICARE, or Medicare’s role in paying for care can result in missed reimbursement demands or post-settlement denial of care, problems that could have been avoided with proper coordination.
How We Help
At Synergy, we’ve seen too many cases where failure to understand TRICARE, VA & Medicare benefit coordination has been costly and exposed firms to unnecessary risk. Our team handles the nuanced resolution of VA liens, TRICARE liens, and conditional Medicare payments to protect everyone involved. We believe trial lawyers and their teams should be focused on getting justice, not deciphering overlapping federal benefits. That’s where our expertise comes in.
Final Thought
If your client has any combination of Medicare, TRICARE, or VA benefits, don’t assume that standard Medicare coordination applies. Each program has its own rules, and they don’t always play nicely together. Engage an expert early. Know who paid what. And protect your client’s recovery by engaging experts before funds are disbursed.
Contact Synergy today. Our team of MSP compliance experts can resolve even the most complicated scenarios, so you don’t have to worry.
Written by: By Jason D. Lazarus, J.D., LL.M., MSCC | Founder & Chairman of Synergy | Founder of Special Needs Law Firm | Author of Amazon Best Sellers – Art of Settlement & Litigation to Life | Host of Trial Lawyer View by Synergy Podcast | Peak Practice by Synergy Curator
For personal injury firms, lien resolution is one of the most time-consuming and risk-heavy aspects of personal injury practice. Every lien has the potential to cut into your client’s net recovery and expose your firm to liability if mistakes are made. The challenge? Not every lien is created equal. Some demand specialized expertise, while others are more efficiently handled in-house.
Knowing which liens to outsource, and which to resolve internally, is essential to protecting both your clients and your practice.
Liens That Should Be Outsourced
Certain liens are simply too complex, too time-intensive, or too risky for most law firms to manage effectively on their own. These include:
- Medicare Conditional Payments – Governed by strict timelines and regulatory processes, with penalties for missteps.
- Medicare Advantage (Part C) Liens – Often enforced by aggressive recovery contractors with deep resources who seek double damages if you fail to repay.
- Medicaid Liens – Highly state-specific, requiring expertise in varying third-party liability statutes.
- ERISA Plan Liens – Backed by federal preemption and difficult plan language, often favoring reimbursement.
- FEHBA & Military Plan Liens – Complex federal programs with unique recovery rights.
- Private Health Insurance & Hospital/Provider Liens – Frequently involve aggressive billing practices and balance billing disputes.
These liens are best handled by professionals who negotiate them daily. Outsourcing here means fewer errors, better results, and more time for your firm to focus on trial work.
Liens Best Kept In-House
Not every lien type justifies outsourcing. Some are more straightforward or are better managed locally:
- Small Liens ($2,000 or less) – Costs of outsourcing may outweigh potential savings.
- Local Provider Liens – Especially when your firm has established relationships with the provider.
- Workers’ Compensation Liens – Governed by state-specific statutes, often better handled locally.
- Medicaid Estate Recovery Liens – State-driven with unique procedural requirements.
- Child Support Liens – Typically statutory and straightforward in enforcement.
- Pre-Settlement Funding Liens – Governed by contract law, often requiring simple verification.
These liens are usually not complex enough to require outside expertise and can be resolved more cost-effectively by your team.
Why This Decision Matters
The decision to outsource isn’t just about convenience, it’s about strategy. Making a mistake with a Medicare or ERISA lien can expose a firm to government enforcement or malpractice claims. Overpaying a hospital lien can reduce your client’s recovery and erode trust. On the other hand, outsourcing small, straightforward liens can create inefficiencies and unnecessary costs.
Striking the right balance allows your firm to:
- Maximize client recovery by ensuring complex liens are aggressively negotiated.
- Reduce liability by leaving high-risk liens to experts.
- Improve efficiency by handling routine liens internally.
Final Thought
Not all liens are created equal and not all should be outsourced. The key is knowing where your firm’s expertise ends and where outside specialists can add value. By strategically deciding which liens to keep in-house and which to outsource, trial lawyers can protect client recoveries, reduce liability, and run a more efficient practice.
At Synergy, we know which battles are worth fighting and how to win them. For the liens that carry the most risk and complexity, our team brings unmatched expertise to the table.
Written by: By Jason D. Lazarus, J.D., LL.M., MSCC | Founder & Chairman of Synergy | Founder of Special Needs Law Firm | Author of Amazon Best Sellers – Art of Settlement & Litigation to Life | Host of Trial Lawyer View by Synergy Podcast | Peak Practice by Synergy Curator
Personal injury law firms live in the courtroom. Their core focus is proving causation, liability, and damages not negotiating with Medicare, ERISA plans, or hospital billing departments. Yet, as every law firm knows, cases don’t truly end at settlement. They end when liens are resolved, and final disbursement is made.
And here lies the dilemma: lien resolution is time-consuming, highly technical, and fraught with risk. Increasingly, law firms turn to outsourcing as a solution. But the question many lawyers ask is, is it ethical to outsource lien resolution?
The answer is yes, when done correctly.
Ethics Matter in Outsourcing
Outsourcing lien resolution isn’t just a business decision. It’s a professional responsibility decision. Mishandling liens can expose clients to ongoing claims, delay disbursement, or even trigger penalties such as Medicare’s double damages provision. Worse, it can expose the attorney to malpractice risk.
The ABA and state bar associations recognize that outsourcing is both permissible and often beneficial, so long as lawyers follow specific ethical safeguards.
ABA Guidance on Outsourcing
ABA Formal Ethics Opinion 08-451 provides clear direction: lawyers may outsource legal and non-legal support services, but they retain ultimate responsibility. That means:
- Supervision: Attorneys must oversee outsourced lien resolution work and ensure it meets professional standards.
- Confidentiality: Client information must remain protected, just as if it were handled in-house.
- Reasonableness of Fees: Costs must be transparent, reasonable, and disclosed to the client.
In short, outsourcing requires active oversight to ensure compliance with ethical obligations.
State-Specific Ethical Rules
Many states echo the ABA’s position, often adding their own guidance:
- New York allows outsourcing as long as fees are disclosed and result in a net client benefit.
- Ohio and Utah emphasize obtaining informed client consent and ensuring costs are both reasonable and transparent.
This growing consensus makes it clear: outsourcing is not only permissible but also practical, provided ethical safeguards are followed.
Ethical Outsourcing Benefits Clients
At its core, outsourcing lien resolution ethically is about client protection. Done properly, it:
- Maximizes Client Recovery by ensuring liens are challenged, audited, and negotiated effectively.
- Reduces Risk by avoiding errors that could trigger legal or financial exposure for both client and attorney.
- Enhances Trust by giving clients confidence that every dollar possible is preserved in their recovery.
Final Thought
Trial lawyers shouldn’t hesitate to bring in lien resolution experts, so long as they do so ethically. By supervising outsourced work, securing client consent, and partnering with trusted providers, firms can meet their professional obligations while achieving better results for their clients.
At Synergy, ethical lien resolution is at the heart of what we do. We partner with trial lawyers nationwide to reduce risk, improve client outcomes, and protect the integrity of every settlement we are involved in.
Written by: By Jason D. Lazarus, J.D., LL.M., MSCC | Founder & Chairman of Synergy | Founder of Special Needs Law Firm | Author of Amazon Best Sellers – Art of Settlement & Litigation to Life | Host of Trial Lawyer View by Synergy Podcast | Peak Practice by Synergy Curator
In our previous blog, we tackled the Medicare conditional payment resolution process. However, if your client, during treatment for their injuries, switched to a Medicare Advantage Plan (MAO-Part C), the resolution process might not be over. Here’s why: While you may have resolved conditional payments with Medicare Parts A and B (traditional Medicare), MAO plans operate independently and may have covered some or all of your client’s medical expenses.
The issue arises because MAO plans are distinct from traditional Medicare, and beneficiaries can enroll in them during specific periods. Consequently, even if you resolved Medicare conditional payments, an MAO might have stepped in later, without your knowledge. CMS will not notify you about these MAO payments, and beneficiaries often lack clarity on their coverage types so it can easily be missed.
To verify MAO plan coverage, clients can check their status on MyMedicare.gov. Additionally, the 2020 PAID Act requires CMS to report MAO enrollments for the past three years, though access to this data is limited to Non-Group Health Plan Responsible Reporting Entities (RREs). You might need to request this information from the defense or painstakingly review medical bills to uncover potential MAO liens.
Attorneys must be vigilant, conducting thorough due diligence to uncover possible MAO liens. Failure to address these could result in double damages, as MAOs do enforce their reimbursement rights aggressively. The Medicare Secondary Payer Act grants MAOs the right to sue for double the lien amount if not repaid, a risk highlighted by cases like Humana v. Western Heritage Ins. Co. Here, Humana successfully claimed double damages after Western Heritage failed to reimburse a $191,000 lien.
To prevent such pitfalls, start your investigation early upon client intake, continue throughout representation, and finalize it before disbursing settlement funds. Identify any MAO liens and seek reduction or compromise as appropriate. Understanding and managing MAO liens is crucial to safeguarding your firm against significant financial exposure for this hidden lien.
Working with specialized lien resolution companies can provide essential expertise and prevent costly mistakes when it comes to Medicare Advantage plan liens. If you want to find out more, contact us today to Partner with Synergy for lien resolution.
Written by: By Jason D. Lazarus, J.D., LL.M., MSCC | Founder & Chairman of Synergy | Founder of Special Needs Law Firm | Author of Amazon Best Sellers – Art of Settlement & Litigation to Life | Host of Trial Lawyer View by Synergy Podcast | Peak Practice by Synergy Curator
Personal injury firms excel at what they were built to do: securing justice by proving liability, telling their client’s story, and getting the best possible settlement or verdict. Yet once the dust settles, another challenge arises, resolving liens.
Here’s the hard truth: lien resolution, while critical, is not a law firm’s core competency. And that reality carries real costs for firms that try to manage it in-house.
The Problem with Keeping Lien Resolution In-House
Handling liens requires a completely different skill set than litigating cases. Instead of cross-examining witnesses or preparing exhibits, lawyers and staff must wade through:
- Complex regulations governing Medicare, Medicaid, ERISA, FEHBA, and private health plans.
- Deal with aggressive recovery contractors like Rawlings, Equian, Optum, and Conduent—organizations whose sole job is to extract repayment from settlements.
- Time-consuming negotiations and audits to dispute unrelated charges and reduce repayment obligations.
This is not advocacy in the courtroom. It is administrative, regulatory, and negotiation-heavy work. And every hour spent on it is an hour taken away from moving existing or new cases toward resolution.
The Cost
When law firms try to resolve liens internally, they often pay the price in three ways:
- Lost Time – Staff and attorneys bogged down in lien disputes can’t focus on case strategy or trial preparation.
- Financial Risk – Missteps with Medicare or Medicaid can result in penalties, interest, or even double damages against the firm.
- Diminished Client Outcomes – Overpaying liens or failing to challenge invalid claims directly reduces a client’s net recovery and client satisfaction.
In short, doing lien resolution in-house diverts resources from your true strength: client advocacy and the pursuit of justice for those who are injured.
Why Outsourcing Is a Strategic Advantage
Outsourcing lien resolution isn’t about passing off busywork. It’s about recognizing that lien resolution is a specialized discipline requiring expertise, focus, and leverage.
- Deep Expertise: Lien resolution professionals live and breathe this work. They know the nuances of ERISA reimbursement provisions, Medicare conditional payments, and Medicaid state-specific rules.
- Leveling the Playing Field: Recovery vendors are massive corporations with teams dedicated to enforcing liens. Outsourcing ensures your client has equally sophisticated representation on their side.
- Better Financial Outcomes: Specialists know how to audit, negotiate, and challenge overreaching claims, often securing significant reductions for injury victims.
- Efficiency: By removing lien resolution from your team’s workload, you free up resources to focus on litigation and client service—the heart of your practice.
The Ethical Considerations
It’s not just about efficiency. ABA Model Rule 1.15 makes it clear: lawyers must protect third-party claims on settlement funds. That means missing a lien or paying one improperly isn’t just risky; it could be an ethical violation. Outsourcing to experts helps ensure compliance while safeguarding your firm’s reputation.
Conclusion
Trial lawyers already outsource to other experts in certain areas of their practices. Lien resolution is similar since it is not your firm’s core competency and treating it as such can be costly. By outsourcing to trusted experts, you not only protect your clients’ recoveries but also protect your practice from liability, inefficiency, and reputational harm.
At Synergy, lien resolution is what we do, day in and day out. Let us handle the complexity so you can get back to doing what you do best: winning cases and serving your clients.
Written by: By Jason D. Lazarus, J.D., LL.M., MSCC | Founder & Chairman of Synergy | Founder of Special Needs Law Firm | Author of Amazon Best Sellers – Art of Settlement & Litigation to Life | Host of Trial Lawyer View by Synergy Podcast | Peak Practice by Synergy Curator
Correctly navigating Medicare’s conditional payment resolution process is critical for personal injury attorneys, given the complex legal framework and the substantial risks involved in failure to reimburse. Under the Medicare Secondary Payer Act (MSPA), the Centers for Medicare & Medicaid Services (CMS) have broad powers to recover payments made on behalf of Medicare beneficiaries, including the right to sue trial attorneys directly. Failing to address Medicare’s reimbursement claims correctly can lead to severe financial and legal consequences for personal injury law firms.
MSPA: The Legal Framework
CMS can recover conditional payments from any entity that touches settlement dollars which are meant to reimburse medical expenses, including attorneys who handle personal injury settlements. The case of U.S. v. Harris starkly illustrates the potential pitfalls. In this case, a personal injury attorney was held liable for Medicare’s conditional payments despite settling a claim and notifying Medicare. The court ruled against the attorney, emphasizing that CMS’s rights under 42 U.S.C. § 1395y(b)(2) extend to recovering from entities that have received payments from primary plans, a personal injury law attorney.
A Labyrinth: The Medicare Resolution Process
Resolving Medicare’s conditional payments involves several steps:
- Initial Reporting: Contact the Benefits Coordination & Recovery Contractor (BCRC) before settlement to obtain a Conditional Payment Letter (CPL). This letter is preliminary and should be audited to remove unrelated care.
- Final Demand: After settlement, Medicare must be informed, and a Final Demand will then be issued. Payment must be made within 60 days to avoid interest accumulation and potential enforcement actions by the DOJ.
Mistakes to Avoid: Common Pitfalls
There are some common mistakes made by personal injury law firms when it comes to conditional payments. These mistakes can be costly, and it is best to avoid them:
- Relying on Conditional Payment Letters: Conditional Payment Letters are not final. Only a Final Demand Letter from Medicare confirms the amount due and is binding. Relying on preliminary figures can lead to significant shortfalls and legal issues, as evidenced by a 2019 case where a Maryland law firm settled a claim which was based upon reliance on incorrect figures in a Conditional Payment Letter.
- Improper Resolution Channels: Using incorrect methods to resolve conditional payments, such as state court proceedings instead of the required administrative processes, can result in severe repercussions, as seen in a Texas case where a state court ruling was sought to reduce what was owed to Medicare which wasn’t effective. Instead, the trial attorney was sued by the government for failure to properly reimburse Medicare.
Reducing What is Owed: Appeals, Compromises, and Waivers
When dealing with Medicare’s repayment formula, attorneys face a rigid calculation per the applicable regulation. The calculated repayment amount often doesn’t account for case-specific details impacting the recovery such as liability issues or policy limits. To address this fact, attorneys can:
- Appeal: Navigate through Medicare’s multi-level internal appeal process, which is lengthy, and interest accrues during the appeal.
- Request Compromise/Waiver: After paying the Final Demand, attorneys can request a compromise or waiver, potentially leading to a refund. Requests can be made under:
- Section 1870(c): Financial hardship waiver.
- Section 1862(b): Best interest of the program waiver.
- Federal Claims Collection Act: General compromise request.
Conclusion
Effective resolution of Medicare conditional payments requires diligence and adherence to proper processes prescribed by Medicare. Attorneys should avoid relying on preliminary figures, ensure timely and accurate reporting, and use appropriate channels for appeals or compromise/waiver requests. Understanding and navigating Medicare’s complex requirements is crucial to safeguarding against personal liability and ensuring successful settlement outcomes.
Working with specialized lien resolution companies can provide essential expertise and prevent costly mistakes when it comes to Medicare conditional payments. If you want to find out more, contact us today to Partner with Synergy for lien resolution.
Written by: By Jason D. Lazarus, J.D., LL.M., MSCC | Founder & Chairman of Synergy | Founder of Special Needs Law Firm | Author of Amazon Best Sellers – Art of Settlement & Litigation to Life | Host of Trial Lawyer View by Synergy Podcast | Peak Practice by Synergy Curator
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