Medical Providers Not Required To Bill Medicare and Medicaid in Personal Injury Cases

hospital.jpgIn every serious personal injury case in Florida, the issue of who will pay the medical providers and how much always arises. Needless to say, providers want to recover as much as they can. Patients, of course, want to pay as little as possible out-of-pocket. How this plays out often depends on who pays the bills.

The different pay sources include health insurance, PIP (motor vehicle insurance), workers’ compensation, the patient (self-pay), the tortfeasor (out-of-pocket), bodily injury liability coverage, UM/UIM (motor vehicle insurance), Medicare and Medicaid.

Various laws dictate who pays what and when. In some instances, the only available sources are Medicare or Medicaid (M/M) and bodily injury liability and/or UM/UIM. Since M/M provide some of the lowest reimbursement rates and providers accepting M/M payments are not allowed to balance bill their patients, in terms of raw numbers it is often to the victim’s advantage for M/M to pay the providers. While victims will ultimately have to reimburse M/M from their recovery in the personal injury case, the amount of the reimbursement is almost always less than what must be paid to the provider directly from the third party recovery (1st party if from UM/UIM).

Where applicable, medical providers typically are required by law or contract to bill payers like workers’ compensation insurance, PIP, and health insurance. Are they required to bill Medicare and Medicaid? Surprisingly, the answer is No.

Medicare and Medicaid are federal programs that provide medical insurance to various classes of individuals. Medicare is for qualified elderly and disabled persons, see 42 U.S.C., §§1395 et.seq., Medicaid is for individuals who cannot afford to pay their own medical costs. See 42 U.S.C. §§1396 et seq. Both programs are secondary payers as to medical expenses for which some other entity (e.g., a tortfeasor) bears responsibility. Medicare — 42 U.S.C. § 1395y(b)(2), Medicaid — 42 U.S.C. §§ 1396a(a)(25)(A), (B), (H). While M/M, when billed, will pay even when a tortfeasor is primarily responsible, the consequence of the federal secondary payer laws is that medical providers cannot be forced to bill M/M.

Some medical providers will bill M/M without hesitation, others will not, calculating that it is more beneficial to hold out for a better pay day down the road than to secure a smaller payment quickly. While this is understandable, it can sometimes be an impediment to resolving a case. It is not uncommon for a large medical bill to be the stumbling block to an out-of-court settlement.

This is just one example of the many issues that arise in Florida personal injury cases.

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