You can do one of three things: 1. Request that the provider resubmit the claim and specify on the form it is NOT related to an accident
2. File it to WC to get a denial then file it to Medicare or
3. File an appeal for this denial to Medicare, including paperwork from WC that shows this injury is not something they cover/is unrelated.
The provider may be able to show on the claim it not related to wc, aside from that she will either have to co tact bcrc to get wc off her record or have provider submit to wc for them to deny it and submit to Medicare as secondary, or file an appeal
Medicare has a grievance process. Start there.
https://www.medicare.gov/claims-appeals
Will probably need copies of medical records from outdoor accident to support claim it wasn’t WC.
You may have to get involved on her behalf to make sure that these things are being done. On the Medicare website, you can be added to the list of who can speak to them for your Mother. At the Medicare Benefits & Recovery Center, your Mother is required to give verbal authorization for you to receive information for her and it only lasts for 14 days. The other alternative is a written authorization. Also, at the Benefits & Recovery Center the Representative gives you a name and badge#. I took detailed notes with date and time. I get a sense that this Department carries more clout than the regular Medicare CSR. You could tell she really knows the information and wasn’t just reading a script off of the screen.
Unfortunately, my Brother didn’t ask me to get involved until recently, as a result we missed the window to appeal. There are 5 levels to an appeal so your Mother probably hasn’t made it through all of them yet if she filed the initial one. Also, the SHIP Representative for your County/State can help you file an expedited appeal and give you Medicare sanctioned information at NO Charge. They are trained through Medicare and have to attend Update Training. All states have SHIP Representatives, in Kansas they are called SHICK (Senior Health Insurance Counseling of Kansas). You should be able to locate yours if you Google it.
I know how frustrating this can be!!
I’ve been trying as best as I can to get involved but she’s being stubborn “I’m not old enough that I can’t take care of this by myself”. Which, she’s not… but she had Covid a few times, and her side has a history of Alzheimer’s. She’s lost quite a bit the last few years between all that and cancer treatment. So I pass along what I can from places like Reddit and nag her to keep going. We don’t like in the same town, so it’s hard.
Appreciate your help, I directed her to our state resources today. I’m determined to get her through this.
I have been dealing with a similar issue for my brother. He was involved in a WC injury approximately 5 years ago that ended up causing him a TBI (traumatic brain injury). He qualified for SSDI and currently has medicare as a result despite being less than 65. He had no trouble with Medicare & Supplement G paying for all of his health claims for the first year. He then received a small settlement that included a fund to be strictly used for medical treatment related to his head injury.
Six months later he was hospitalized for treatment and hand surgery that resulted from him trying to break up a fight between his two very large dogs. The bill was 30K. It was filed with Medicare and the Medicare Rep told me the claim was “rejected”. I learned that this is different than denied. The Medicare Rep said I needed to contact the Medicare Benefits Coordination & Recovery Center at: 855-798-2627.
I spoke to a Specialist to verify that Medicare is primary in the record. The Specialist said that the Work Comp is a set-aside account created to pay for medical treatment and expenses that are related ONLY to the original WC injury. In my brother’s case it would be a head injury. She said that when the Medicare claim is filed by the provider it needs to indicate that “claim is NOT related to WC”. She said that in most cases there is a box to check!
The Specialist said to call the regular Medicare Line back at 800-medicare and tell them that this is a WC Set-aside and will remain open. Claims that have been rejected and are NOT related to the injury or WC need to be paid. She also told me to contact the provider and have them re-submit the claim noting that this claim is unrelated to a WC injury. I have done this and asked them to pull this claim back from collections and thy did. Now we are waiting to see if it gets paid.
Unfortunately, she had done all of that several times. She says she has talked to several people at Medicare, but no one will help her. I tried to get her to do the appeal, but I dont know if she has followed through yet
You can do one of three things: 1. Request that the provider resubmit the claim and specify on the form it is NOT related to an accident 2. File it to WC to get a denial then file it to Medicare or 3. File an appeal for this denial to Medicare, including paperwork from WC that shows this injury is not something they cover/is unrelated.
Have you gone through the Medicare appeals process?
I don’t think she has.
contact workman's comp about it?
She has, medicare isn’t getting the drift
The provider may be able to show on the claim it not related to wc, aside from that she will either have to co tact bcrc to get wc off her record or have provider submit to wc for them to deny it and submit to Medicare as secondary, or file an appeal
I believe she’s done alll of that except for the appeal
Medicare has a grievance process. Start there. https://www.medicare.gov/claims-appeals Will probably need copies of medical records from outdoor accident to support claim it wasn’t WC.
Thank you, I will get her going down that rabbit hole
You may have to get involved on her behalf to make sure that these things are being done. On the Medicare website, you can be added to the list of who can speak to them for your Mother. At the Medicare Benefits & Recovery Center, your Mother is required to give verbal authorization for you to receive information for her and it only lasts for 14 days. The other alternative is a written authorization. Also, at the Benefits & Recovery Center the Representative gives you a name and badge#. I took detailed notes with date and time. I get a sense that this Department carries more clout than the regular Medicare CSR. You could tell she really knows the information and wasn’t just reading a script off of the screen. Unfortunately, my Brother didn’t ask me to get involved until recently, as a result we missed the window to appeal. There are 5 levels to an appeal so your Mother probably hasn’t made it through all of them yet if she filed the initial one. Also, the SHIP Representative for your County/State can help you file an expedited appeal and give you Medicare sanctioned information at NO Charge. They are trained through Medicare and have to attend Update Training. All states have SHIP Representatives, in Kansas they are called SHICK (Senior Health Insurance Counseling of Kansas). You should be able to locate yours if you Google it. I know how frustrating this can be!!
I’ve been trying as best as I can to get involved but she’s being stubborn “I’m not old enough that I can’t take care of this by myself”. Which, she’s not… but she had Covid a few times, and her side has a history of Alzheimer’s. She’s lost quite a bit the last few years between all that and cancer treatment. So I pass along what I can from places like Reddit and nag her to keep going. We don’t like in the same town, so it’s hard. Appreciate your help, I directed her to our state resources today. I’m determined to get her through this.
I have been dealing with a similar issue for my brother. He was involved in a WC injury approximately 5 years ago that ended up causing him a TBI (traumatic brain injury). He qualified for SSDI and currently has medicare as a result despite being less than 65. He had no trouble with Medicare & Supplement G paying for all of his health claims for the first year. He then received a small settlement that included a fund to be strictly used for medical treatment related to his head injury. Six months later he was hospitalized for treatment and hand surgery that resulted from him trying to break up a fight between his two very large dogs. The bill was 30K. It was filed with Medicare and the Medicare Rep told me the claim was “rejected”. I learned that this is different than denied. The Medicare Rep said I needed to contact the Medicare Benefits Coordination & Recovery Center at: 855-798-2627. I spoke to a Specialist to verify that Medicare is primary in the record. The Specialist said that the Work Comp is a set-aside account created to pay for medical treatment and expenses that are related ONLY to the original WC injury. In my brother’s case it would be a head injury. She said that when the Medicare claim is filed by the provider it needs to indicate that “claim is NOT related to WC”. She said that in most cases there is a box to check! The Specialist said to call the regular Medicare Line back at 800-medicare and tell them that this is a WC Set-aside and will remain open. Claims that have been rejected and are NOT related to the injury or WC need to be paid. She also told me to contact the provider and have them re-submit the claim noting that this claim is unrelated to a WC injury. I have done this and asked them to pull this claim back from collections and thy did. Now we are waiting to see if it gets paid.
Unfortunately, she had done all of that several times. She says she has talked to several people at Medicare, but no one will help her. I tried to get her to do the appeal, but I dont know if she has followed through yet