When Workers' Compensation Pays Instead of Medicare

Published 01/04/2021

If a beneficiary has a work-related illness or injury, services provided for treatment of that illness or injury should be covered by workers' compensation (WC) or federal Black Lung benefits. It is important that the Medicare claim form note that the treatment is related to a work-related illness or injury, even if the injury or illness occurred in the past.

While you are awaiting a decision from the WC board, you may submit the claim to Medicare. Include a copy of the decision pending notice from the WC board with the claim. Medicare will issue a conditional payment, which must be refunded if the claim is subsequently approved by WC. The person who received the payment from Medicare will be contacted about the refund.

Payment under Medicare may not be made for any claims if payment has been made or can be made under a corkers' compensation law or plan of the United States or any state, or under the federal Black Lung program.

If WC cannot make payment for claims because they were furnished by a source not allowed by WC, Medicare can pay for those claims.

Provider Responsibilities Concerning Workers' Comp
Providers are responsible for taking whatever action is needed to obtain payment under WC. This includes filing a timely claim and furnishing all needed information required to receive payment. If failure to take proper and timely action results in a loss of WC payment, Medicare benefits are not payable to the extent that payment could have been made under WC.

Where WC does not pay for all services furnished to a beneficiary, Medicare benefits may be paid for those services not covered under WC. Payments made under WC cannot be applied toward the Medicare deductibles. Medicare cannot pay second to WC claims.

When services are covered in part by WC and also under automobile medical or no-fault insurance, WC pays first and the automobile medical or no-fault insurance pays second.

If a WC agency approves a lump sum settlement of a case that is contested, the lump sum settlement is deemed to be a WC payment, even if the settlement agreement stipulates that there is no WC liability.

If an individual signed a final release of all rights under WC, claims incurred after the date of the final release are covered by Medicare, as long as the claims were not addressed in the settlement.

Medicare may recover from WC whether or not the beneficiary is filing a WC claim with respect to the injuries.

Medicare may also recover from the employer. Medicare may also recover money from anyone paid by WC or the employer.

Medicare will deny any claim that WC will cover, or where you expect WC to cover the claim. Palmetto GBA will look for claims related to the injury.

CMS regulation reference: Publication 100-05, Chapter 1 (PDF, 191 KB).

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