Avoiding Multiple and Duplicate Medicare Files

Medicare can and will open multiple files for a plaintiff’s motor vehicle accident case or workers’ compensation case. In those scenarios, that process is usually correct. In turn, Medicare might open multiple files for a plaintiff’s medical malpractice or other liability case. In this scenario, we think Medicare’s file is probably a duplicate. How do you avoid these duplicates? 

 

Start by looking at Section 111 Reporting (also known as Mandatory Insurer Reporting). Defendants are required to report all settlements and judgment to Medicare. If their reporting information doesn’t match something Medicare has already opened, like your file, then a new file will be opened. The most common reasons for a duplicate or additional file are: 

• Different Dates of Injury: We see differing DOIs most often in nursing home or bedsore cases. 
  • Your easiest solution is to discuss Section 111 reporting prior to settlement. This discussion isn’t about plaintiff and defense attorney agreeing on a date. It is about the plaintiff attorney and the defense’s reporting agent/team agreeing on the correct date. Later, incorporate the date of injury into your settlement release. 
• Different Settlement Amounts: This issue is usually a question of multiple defendants in one settlement. A plaintiff might see $100,000 as the settlement amount. Medicare is going to learn about $50,000 from Defendant A and $50,000 from Defendant B.  
  • Your solution is to report clear settlement information to Medicare – either as two settlements or as one, but with proper identification of the sources specifically citing the separate $50,000 payments of this example. 
• Multiple DOIs In One Payment: This scenario is trickier because you may not realize you are settling both cases with one release.  
  • Your solutions are broader but require planning and discussion regarding how the defense is reporting Section 111 reporting. Perhaps you choose to tell Medicare one DOI’s case is closed. Or wait to open the plaintiff Medicare file until your DOI decision is made. Regardless, the defense reporting needs to match. 

 

Consider this scenario in a nursing home case. The plaintiff is admitted to the nursing home on January 1. On February 15, the family notices bed sores on plaintiff’s back. The plaintiff is transferred to a hospital. When is the injury date? January 1 seems too early, but February 15 seems late. If the plaintiff’s representatives report February 15 to Medicare, but the defense reports February 1 – you will end up with two files. 

 

Medicare is much more forgiving if plaintiff’s reporting is earlier than defense’s because it has had a chance to claim payments it made in the interim period. Regardless, Medicare will open two Medicare – Liability files. One for DOI February 15 and another for DOI February 1.  Solve this by having an open discussion between plaintiff and defense. 

 

Practice Tips:

• Open the Medicare file early
• Use Medicare’s Case ID (and ask does it match defense’s Medicare reporting)
• Search Medicare’s portal via DOI, not Case ID to check properly
• Include Medicare datapoints in settlement agreements:  
  • Date of Injury 
  • Settlement Amount  
  • ICD Codes for “Injuries Reported.”