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Medicare’s Self-Calculated Payment Amount: Pros and Cons

Yesterday we wrote about a new way to resolve Medicare Liens in our post: MSPRC to Offer Pre-Settlement Final Demands.  In that post we promised to analyze the pros and cons at a later date.  We stick to our promises at Lien Resolution Services.


The Benefits of Medicare’s Self-Calculated Payment Amount

  • The most obvious benefit of Medicare’s new Self-Calculated Payment Amount is that you can finally know the lien when you settle.  No more blindly settling when you only have a Conditional Payment Summary.
  • While there isn’t much else – there is the benefit of knowing the MSPRC is at least trying this process.  Perhaps they will expand it for the future.


The Disadvantages of Medicare’s Self-Calculated Payment Amount

First you need a Conditional Payment Letter (“CPL”) from the MSPRC.  That process takes about 90 days starting with the reporting to the COBC.  Then, you need to mark that CPL with Ys and Ns referring to what does apply (Y / Yes) and what does not apply (N / No).  Amazingly, the MSPRC then wants you to look at mymedicare.gov and add any claims that are related to the case.  Continuing on, the MSPRC requires model language for the option.  Finally, you will attach the attestation (physician or beneficiary certification).

  • The process is only applicable where many criteria are met:
    • The settlement is for a Liability file only (no PIP, Med-Pay, Workers’ Compensation, or other No-Fault insurance);
    • The total settlement value is less than $25,000.00;
    • The settlement is for a Trauma-based injury (no ingestion, exposure, or medical implants and therefore no products liability or mass tort type cases);
    • The date of incident is more than 6 months ago;
    • The beneficiary demonstrates that treatment is complete and no further treatment is expected through:
      • A written physician attestation; or,
      • A written certification from the beneficiary that:
        • No medical treatment related to the case has occurred for at least 90 days; and,
        • No further care is expected.
  • The time frame for lien resolution does not improve.  Think about it: You still have to wait for the Conditional Payment Summary (which requires waiting for a Rights and Responsibilities letter first); Then you have to go through the self-calculation process; and finally, You wait for the MSPRC response.  Only after that process can you request a Final Demand for the Medicare lien.
  • Through all of this you end of waiving one of the most important rights to Medicare lien resolution – the appeals process.  You’re giving up four levels of Medicare lien appeals.

This post is mostly negative.  But the Medicare Self-Calculated Payment process is applicable in very narrow situations.  Nonetheless this is a step in the right direction – perhaps the MSPRC expands applicability of the process.


Ryan J. Weiner
Co-Founder Lien Resolution Services
Twitter: @LienResolve
This Blog/Web Site is made available by the publisher for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice. By using this blog site you understand that there is no attorney client relationship between you and the Blog/Web Site publisher. The Blog/Web Site should not be used as a substitute for competent legal advice from a licensed professional attorney in your state.

About Ryan J. Weiner

Co-Founder of Lien Resolution Services, LLC, a national healthcare lien resolution firm. Our goal is to assist in the fair administration and resolution of healthcare liens on personal injury cases. Please visit our website for more information: www.lienresolutionusa.com.

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