Medicare and Workers' Compensation: Essential Information to Understand
Workers' Compensation and Medicare: Navigating the Necessary Connection
It's vital to inform Medicare about workers' compensation arrangements to avoid claim rejections and costly reimbursements. Here's a friendly guide on how and when to make those important reports:
Sharing Workers' Compensation Info with Medicare
Who's in Charge:
Insurance carriers, self-insured employers, and third-party administrators (TPAs) should be the ones responsible for reporting through the Section 111 reporting process.
What to divulge:
Disclose settlement details, such as the amount, Workers' Compensation Medicare Set-Aside (WCMSA) allocation, and the funding mechanisms (lump sum or annuity).
Timing is Crucial:
Reporting must take place for all full and final settlements involving Medicare beneficiaries, effective April 4, 2025. This includes settlements approved and payable on or after this date, or when the settlement agreement is signed if no judge approval is required.
The Importance of Reporting
Sharing settlement details helps Medicare protect its interests by ensuring that future medical care expenses covered by Medicare are accounted for within the workers' compensation settlement.
Failing to report may lead to civil penalties or the denial of Medicare benefits for related injury-related medical care.
Steps to Compliance
- Internal Processes Review: Update internal processes to manage workers' compensation settlements effectively.
- Work with Legal: Collaborate with legal teams to ensure all reporting obligations are met.
- Training: Offer training to claims adjusters and legal teams on CMS updates to prevent misreporting.
- Stay Informed: Keep up to date with new developments and policy changes through CMS communications.
Need More Details?
Check out our Medicare hub for more resources to help you navigate the complex world of medical insurance.
[1] Medicare Learning Network
[2] CMS.gov
- To avoid reimbursement issues and potential claim rejections, it's essential for insurance carriers, self-insured employers, and third-party administrators (TPAs) to follow the Section 111 reporting process, especially when dealing with healthsystems related to health-and-wellness, therapies-and-treatments, nutritional care, and the science behind them, as they might be covered under Medicare.
- In the realm of workers' compensation, the failure to disclose settlement details, such as the amount, Workers' Compensation Medicare Set-Aside (WCMSA) allocation, and the funding mechanisms (lump sum or annuity), could lead to civil penalties or the denial of Medicare benefits for related injury-related medical care.
- As providers of health-and-wellness services, it's crucial to understand that sharing settlement details with Medicare assists in protecting Medicare's interests by ensuring that future medical care expenses covered by Medicare are accounted for within the workers' compensation settlement.
- Besides reporting obligations, it's important for workers' compensation systems, Medicare, and healthsystems to be aware of and integrate relevant aspects of health-and-wellness, including nutrition, into their therapies-and-treatments to promote better outcomes for the overall wellbeing of the patients and to avoid any potential conflicts or complications in handling Medicare claims.
