Workers’ Compensation Lawyers’ Blog

Who Pays the Medical Bills: Medicare or Workers’ Compensation?

When a worker who was injured his back on the job, and is collecting workers’ compensation – they still become eligible for Medicare coverage when they turn age 65. when this happens, what was previously  straightforward workers’ compensation coverage can become very confusing in terms of whether Medicare is a secondary or primary payer for medical treatment.

Workers’ compensation insurance companies are required to report claims for any medical treatment to Medicare, for recipients age 65 and older. When that happens, the injured worker may receive what is called a “conditional payment letter.” These are issued if treatment is paid for through Medicare, even though it is the responsibility of the workers’ compensation insurance carrier to cover the treatment.

Medicare vs Workers Compensation Confusion

Because the workers’ compensation program can be cumbersome process, physicians often find it far easier to bill Medicare. Medicare’s reimbursement procedures are in place and they typically pay their bills promptly. Additionally, receiving authorizations for treatment is generally far easier through Medicare than it is through the workers’ compensation system.

However, there is a distinct possibility that Medicare will reject payment of medical expenses if it determines the illness or injury could possibly be related to a prior workers’ compensation claim. Additionally, if Medicare is notified that a workers’ compensation claim exists, Medicare may issue a letter to the employee stating that it was notified that the employee had received a workers’ compensation award.

This is an attempt by Medicare to determine whether or not it paid for medical treatment that should actually be the responsibility of the workers’ compensation insurance company. If Medicare determines that to be the case, it will either: (1.) seek reimbursement from the insurance company; or, (2.) sometimes seek reimbursement from the beneficiary if a settlement payment was already received by the employee.

Determining if a Claim is Medicare or Workers’ Compensation

Let’s take the example of a construction worker, Steve (age 65), who is collecting workers comp for a back injury. While he is receiving treatment for his back, he experiences some tingling and weakness in his right foot. Upon seeking diagnosis and treatment from his primary care physician, which was covered by Medicare, the physician determines the tingling is actually caused by nerve damage associated with his back injury, which is covered under workers’ compensation claim. Because of the severity of the nerve damage, it is important for Steve to get the treatment he needs, and to figure out who pays the medical bill.

This is where our workers’ compensation lawyers can really be helpful. We can help individuals like Steve retrieve all the medical records related to his work injury, and related to subsequent medical conditions. Our attorneys know what is needed, and how to proceed through the maze of the claim process

If you find yourself in a situation similar to Steve’s, our lawyers will advise you to ask your physician to comment specifically in the paperwork if in their medical opinion the condition is related to a prior workers’ compensation injury or it is unrelated. They will also be sure the physician’s notes indicate the final determination of your diagnosis. These documents can be used to help Medicare and your workers’ compensation insurance company decide who should pay the bills.

What to Do if You Get a Letter from Medicare

If you receive a “conditional payment letter”, you should immediately seek the advice of a lawyer, because a response is required within certain time limits. Our Long Beach workers’ compensation lawyers are available to help you explain whether or not the injury was in fact related to a workers’ compensation medical expense, and will advise you what supporting documentation is needed.

It is always a good idea to send a copy of anything you receive from Medicare to your workers’ compensation lawyers so they have everything they need to review and to guide you in your response.

Workers’ compensation is a complicated process, and when you add Medicare into the equation, it is very difficult to manage medical claims on your own. Our Long Beach workers’ compensation lawyers are experienced and knowledgeable in how workers’ compensation insurance and Medicare interrelate, and what needs to happen in order to protect your interests. We are ready and willing to help you deal with these “legalities” so that you can concentrate on getting well.

Long Beach Workers Compensation Lawyers

If you were injured or made ill in the workplace, we recommend that you speak with an experienced workers comp lawyer immediately. Even if you are currently receiving workers comp benefits, it is a good idea to get some legal advice to protect your rights going into the future.

An experienced workers compensation lawyer can help you identify minor issues before they become major problems – and make sure that you not only receive your benefits now, but for years to come.

Your consultation with our workers’ comp lawyers is 100% confidential, and neither your employer nor your insurance company will be notified that you requested a consultation with us. Our lawyers will help you understand your rights and work tirelessly to ensure that you receive the maximum workers’ comp benefits for which you qualify.

Call our Workers Compensation lawyers for a FREE CONSULTATION: 800-964-8047