From IPE: Top 10 Tips for Preventing Subrogation Issues & Handling Subrogation Claims
Top 10 Tips for Preventing Subrogation Issues & Handling Subrogation Claims
Source: IPE Tools of the Trade e-Newsletter
Click HERE to join their mailing list.
Guest Author: April S. Wynn-Buchanan
- Providers of health insurance and benefits generally have the right to determine whether a third party may be responsible for paying for your injuries.
- The most common subrogation claims will involve Medicare [through Centers for Medicare & Medicaid Services/CMS], Medicaid (through the state) or medical payments (through your personal auto policy). In order to handle claims most efficiently, it is best to put these entities on notice as soon as you are aware of their potential involvement, to avoid slowing down the resolution of the claim.
- Medicare has streamlined its process through the Medicare Secondary Payer Recovery Portal (managed by CMS). A process that once took several months to accomplish can now be done in a matter of weeks. Through this portal you are able to; Upload authorizations and a proof of representation form, obtain conditional and demand payment amounts, dispute claims and provide notice of settlement.
- Medicare uses a formula by which their lien amount is reduced to accommodate for case expenses and attorney’s fees; therefore, you cannot obtain a final Medicare Demand Amount until you submit documentation to CMS detailing how funds were distributed from the settlement.
- Medicaid is a much more complicated issue as every state has different requirements and employs different processes. In Ohio, we work directly with the Ohio Tort Recovery Unit in order to reimburse the state for any claims paid due to a liable third party. While the entities collecting these funds will vary from state to state, Medicaid has automatic subrogation rights and must be reimbursed.
- Medical Payments subrogation is typically pretty straight forward. If you are involved in an accident and have medical payments coverage provided under your automobile policy, you are entitled to use those benefits. However, those benefits must be reimbursed if there is a recovery from a third party and the policy providers for reimbursement.
- Many medical providers will bill the medical payments coverage directly if they suspect it may be available. In general, this is because medical payments coverage generally pays a larger percentage of the total billed amount. Therefore, it is extremely important that you alert first party carriers immediately of attorney involvement in a new case. This particular issue can become very complicated when attempting to resolve a case where medical payments have been issued directly to providers, but the liability carrier has “reduced” the billing for one reason or another. In general, medical payments claims providers are unwilling to reduce the amount of their subrogation claim. Therefore, you want to avoid this issue by putting first party insurance companies on notice as soon as you are hired.
- Worker’s Compensation also has subrogation rights when a worker is injured on the job and Workers Compensation is paying the claim. In my personal experience, they tend to have the simplest process regarding subrogation matters.
- Private health insurance may or may not have subrogation rights as it depends largely on the plan language. If a private insurer contacts you regarding their rights, it is best to start by asking for a copy of their plan language. In general, an attorney will need to review this information to determine if those rights are enforceable.
- In closing, all subrogation issues can be handled efficiently and effectively if you are aware of all parties that have an interest in the claim. Notifying them at the beginning of a claim can avoid unnecessary delays in the settlement process.
|April S. Wynn-Buchanan is a paralegal at the Ohio personal injury firm, Kisling, Nestico & Redick, where she has been employed since 2012. April earned her Bachelor’s degree in Political Science from Oberlin College and continued her graduate studies at Case Western Reserve University. April is the proud mother of an 11-year-old son and 1-year-old daughter.