Why was my Medicare claim denied?

Medicare denies workers' comp claimsWe get this question frequently from people who collect workers’ comp benefits past the age of 65. Although most of your medical costs are covered by Medicare once you turn 65, if you're collecting workers’ comp for a work-related injury, Medicare won't pay for anything it thinks should be covered by the Bureau of Workers’ Compensation (BWC).

It can be very frustrating when claims are denied by both programs because one agency thinks the other should pay.

The workers’ comp team at the Monast Law Office can help you sort out these problems.

Workers’ Comp Is the Primary Benefit

The first thing to understand is that workers’ comp is your primary insurance, and Medicare— once you're eligible—will become your secondary insurance. This means that workplace-related medical bills should first go to workers’ comp and, if a claim is denied, then submitted to Medicare.

However, Medicare will only pay for healthcare costs unrelated to your work injury, so if you submit a bill that Medicare thinks should have been paid by workers’ comp, it will be denied.

What Can You Do If Both Insurers Deny Your Claim?

If you're already consulting with a workers’ compensation attorney, bring the issue to his/her attention immediately. If you have no attorney, this might be an excellent time to find one.

This back-and-forth between the BWC and Medicare can go on for a long time, leaving you to suffer in the meantime. An attorney can discover why the claim was denied by workers’ comp and, if the BWC denial is unjustified, s/he'll file an appeal to make sure they pay what you're owed. If Medicare should be paying the cost, your attorney will help you deal with that issue.

Managing Workers’ Comp and Medicare Together

Sometimes, if the BWC is taking a long time to approve a claim, Medicare may make a conditional payment—but once the BWC pays the claim, you must pay Medicare back.

Also, if you settle a workers’ comp claim for a lump sum, you must set up a Medicare Set-Aside (MSA) to pay back Medicare for any work-related costs it covers.

Call Our Team With Your Questions

We understand all this can be confusing--and, frankly, a royal pain. If you're collecting workers’ comp and have questions after a Medicare denial, please call our office in Upper Arlington. We'll give you the necessary information to help receive the benefits to which you're entitled—whether from workers’ comp or Medicare.

Please learn more about workers’ compensation in Ohio by requesting a free download of our book, The Worker’s Guide to Injury Compensation in Ohio

 

James Monast
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Fighting for Ohio’s Injured Workers and their Families