Medical Record Review to Ensure Medicare Eligibility

by | Published on Apr 10, 2014 | Medical Record Review

Workers’ Compensation cases can be really challenging to handle. When it comes to determining eligibility for Medicare, attorneys and insurance companies have to depend on thorough medical record review. Medicare coverage is only for U.S. citizens or permanent U.S. residents who have worked in Medicare-covered jobs for a period of 10 years minimum and are above 65. However, there are exceptions to this rule according to which disabled people younger than 65 also qualify as Medicare candidates. It is important to establish Medicare eligibility for the claimant because federal rules hold it mandatory that before a Workers’ Compensation claim is settled, Medicare interests must necessarily be taken into account.

This is where a professional medical review company can be of tremendous help. It can assist you in drawing up clearly the amount the Medicare system, as the secondary payer, will have to pay the claimant. This rule has been introduced with a view to prevent the compensation burden falling on the shoulders of Medicare. The Medicare set-aside document is important when settling injury claims typically covered by Medicare. This document establishes Medicare as the secondary payer in cases which involve beneficiaries who have other insurance coverage as well. A Medicare set-aside document is required when a claimant is eligible for Medicare and the total amount involved as settlement is $25000 or more. It is also needed when the claimant expects to be enrolled in Medicare within thirty months of the settlement date and the total amount is greater than $250, 000.

Non-compliance with the above requirement of the CMS (Centers for Medicare and Medicaid Services) can prove to be extremely costly. The claimant may lose the eligibility to receive future medical care; the claimant/ his/her attorney/ the insurance carrier may have to face a lawsuit filed by the CMS or find themselves designated their share of the allocation. In addition, the attorney concerned may have to bear the brunt of a malpractice suit for failing to obtain the document.

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