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Medicare Denied Claims and Conditional Payments

Medicare claim denial is unfortunately a common problem that Medicare beneficiaries are faced with. Medicare has the highest denial rate of any insurer pursuant to the 2008 National Health Insurer Report Card commissioned by the American Medical Association (AMA,


Before we start making hasty assumptions about government health care programs, lets look at some of the reasons why claims have been denied by Medicare. 33.6% of adjustments and 33.7% of denials are due to inaccurate reporting by the providers. Some of the common billing errors that providers make are:

  • Submission of incomplete or invalid information.
  • The provider is unable to confirm Medicare status of the patient (requests reimbursement for non Medicare patients).
  • Evaluation and management (E&M) procedure codes and the place of service do match.
  • ICD9 Codes are invalid or incomplete.
  • Claims with a beneficiary that has been involved in an accident are processed incorrectly.

One common error that we (LSS) have assisted many beneficiaries with, is the submission of a claim by a provider to Medicare. The claims are usually for injuries that are un-related to an accident, but are submitted by the provider as “accident related.” With this inaccurate information, the claim is rightfully denied by Medicare. Because Medicare is secondary to all accident related treatment Medicare will deny any claim that they believe has a primary payer. At this point it is now the unfortunate responsibility of the beneficiary, who are often elderly, to deal with the burden of having the claim re-submitted for appropriate payment. For those that have addressed invalid Medicare denied claims, being on the phone for hours simply to reach someone that can assist is time that many of us do not have. These claims that are being denied by Medicare can be avoided if physicians report/submit complete and accurate claims. When a claim is reported/submitted correctly to Medicare not only can we avoid denied claims, but conditional payments can be made by Medicare when appropriate. A conditional payment is a payment made by Medicare for an accident related treatment when:

  • Payment is not received by the primary insurer within 120 days (from the date of service or discharge).
  • The primary payer (insurer) denies the claim.
  • The beneficiary fails to file a proper claim because of physical or mental incapacity.

A conditional payment is made conditioned upon reimbursement to the Medicare Trust Fund at the time of a settlement, judgment, or award. Because it can sometimes take several years for a claim to settle Medicare will make a conditional payment, as it would be unfair to the Medicare provider(s) and the other insurers to withhold payment. In any event, whether we are dealing with the reimbursement of conditional payments or denied claims by Medicare, addressing these matters with the appropriate Centers for Medicare and Medicaid (CMS) offices can be a tedious process. So let’s help Medicare help us. How you can help Medicare have a more efficient claims process, while avoiding future problems with your medical bills:

  • If you have been involved in an accident and the treatment that you are receiving is un-related to the accident, let the provider know that the treatment is un-related to the accident and reinforce that it should be billed to Medicare for primary payment.
  • If the treatment is related to an accident let the provider know. Explain that your primary insurer should be billed “not” Medicare. The provider can later bill as a conditional payment to Medicare if necessary (it is not “required” that the provider submit a conditional payment claim).
  • Do not mention Medicare to your provider for any accident related treatment (per Medicare claims representative). Your primary insurer should be paying.
  • If you are receiving treatment for both un-related and accident related injuries/conditions on the same date of service, and the primary reason for the visit is for un-related injuries/conditions. Confirm with your provider what the primary service is. If the reason for your visit is un-related to the accident, ensure that the physician bills Medicare with explanation of the bill, due to the accident related treatment being provided on the same DOS.

(e.g. You have a liability case open/closed, where you sustained injuries to your neck and low back. On 1/1/09 you receive treatment for an injury to your ankle, which you injured while at “home” and the provider also takes a look at your neck and back, which is related to your liability case. The physician should be billing Medicare, due to the primary service provided being un-related to the liability claim). Remember that Medicare is primary for all OTHER treatment; any treatment related to an accident is the responsibility of the insurer and should be considered primary.

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