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Medicare Liens and Medicare Set Asides

by Kevin P. DeMello, esq.


When a client has medicare that pays for all or part of their medical bills relating to a personal injury case, there are a host of special issues to deal with. Even if a client does not have medicare, but qualifies for social security disability due to an injury, Medicare issues arise if there is the potential for future medical treatment relating to a personal injury.

The basic theory behind the Federal law regarding Medicare in personal injury cases is that Medicare should not have to pay for medical treatment when a person gets compensation for that treatment in a personal injury settlement. Although this seems fair in theory, in reality the Medicare Secondary Payer Act creates all kinds of difficulties that can trap the unwary. In particular, when a claimant has Medicare coverage, there is a requirement that both the claimant and the insurance carrier report any potential personal injury claim to Medicare. Medicare then has the right to demand part of the proceeds in reimbursement of any payments that it has made towards medical bills that relate to the case. This process can take months, and should be initiated very early in the claim process. Often times, Medicare tries to claim reimbursement for unrelated medical bills, and this can create all kinds of delays in settlement.

Another potential issue is when a claimant qualifies for Medicare, but expects future medical treatment as a result of his or her injuries. In that case, Medicare may require the claimant to set aside part of the proceeds of a personal injury settlement in order to pay for that future medical treatment. If this is not done properly, Medicare may deny paying for future medical treatment altogether.

In the context of a workplace injury, where workers compensation coverage is involved, these issues can become even more complicated. Generally, in Massachusetts, the workers compensation carrier is required to pay for any and all related medical charges. However, sometimes medicare pays these charges accidentally. In some cases, the workers compensation carrier is not required to follow the general rule and will deny future medical treatment. In those cases, a Medicare set aside may be required.

At Keches Law Group we have a great deal of experience not only in handling liability and workers compensation claims, but also in dealing with the potential Medicare issues that arise. If you have a personal injury claim, and are on Medicare, or qualify for Medicare, you should contact a competent attorney to help guide you through the ever changing morass of Medicare rules and regulations.

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