Unconditional Delays: The Medicare Effect on Liability Claims

Medicare and money

The Impact of CMS and Medicare Requirements

The healthcare industry is a complex and heavily regulated sector that involves numerous parties, including healthcare providers, insurance companies, government agencies, and patients. Regarding medical liability settlements, delays can often occur due to the requirements imposed by the Centers for Medicare and Medicaid Services (CMS) and Medicare.

CMS is responsible for administering the Medicare program, which provides healthcare coverage to seniors and certain people with disabilities. As a part of its oversight of the program, CMS has established regulations that govern the reporting and reimbursement of medical expenses related to injury claims.

One of the key requirements imposed by CMS is the reporting of claims involving Medicare beneficiaries. When a Medicare beneficiary is injured and files a claim, the healthcare provider must report the claim to CMS within 60 days of settlement or judgment. This reporting requirement is designed to ensure that CMS is aware of the number of medical expenses incurred by the beneficiary and can seek reimbursement for any payments made on the beneficiary’s behalf.

The reporting requirement can often lead to delays in the settlement process, as the healthcare provider must wait for CMS to review and approve the claim before the settlement can be finalized. This review process can take weeks or even months, depending on the complexity of the case and the workload of the CMS staff.

Another CMS requirement that can cause delays in settlement is the process of Medicare Set-Asides (MSAs). An MSA is a financial arrangement that sets aside a portion of the settlement funds to cover the injured party’s future medical expenses related to the injury. CMS requires that an MSA be established for any settlement involving a Medicare beneficiary to ensure that Medicare is not responsible for paying for future medical expenses related to the injury.

The establishment of an MSA can be a complex and time-consuming process, involving the determination of future medical costs, the selection of a custodial account, and the submission of detailed documentation to CMS for review and approval. This process can add significant delays to the settlement process, particularly in cases where the settlement amount is large or the future medical expenses are uncertain.

In addition to the CMS requirements, Medicare also has its own rules and regulations that can cause delays in settlement. For example, Medicare has a statutory right to recover any payments made on behalf of a beneficiary from a third-party settlement. This right of recovery can be complicated to navigate, particularly when there are multiple parties involved in the settlement or when the settlement amount is not clearly defined.

To ensure compliance with Medicare regulations, healthcare providers and insurance companies must often engage in lengthy negotiations with Medicare to determine the proper reimbursement amount. This negotiation process can lead to further delays in settlement, particularly when the parties are unable to reach an agreement.

 the requirements imposed by CMS and Medicare can cause significant delays in the settlement of third-party liability claims. While these requirements are designed to protect the interests of Medicare beneficiaries and the Medicare program, they can add layers of complexity and bureaucracy to an already complicated process. Healthcare providers and insurance companies must be prepared to navigate these requirements and work closely with CMS and Medicare to ensure timely and fair settlements for all parties involved.