Heyl Royster


Heyl Royster


Identifying and Resolving Medicare Issues In Workers’ Compensation Settlements

By: Joe Guyette, Champaign Office

Medicare issues tend to complicate and delay the resolution of a Worker’s Compensation case. It can be difficult to balance the need to settle a claim for a reasonable sum with the need to limit or eliminate Medicare liability, but this is possible with good planning. Whether you are tackling conditional payments, the funding of future medical benefits or post-settlement issues, there are strategies that can be used to keep a case on track.

Conditional Payments

  • An arbitration hearing can be used to limit liability for conditional payments. If an arbitrator decides that certain medical treatment is not related to an accident, those bills will not be included in Medicare’s conditional payment demand.
  • Even after Medicare’s conditional payment demand is finalized, there is an appeal process that can be used to reduce liability. Some of the deadlines for this process are very tight, and it is important to gather necessary information as soon as possible.
  • Medicare will not seek to recover any additional payments for a very small settlement, totaling $750 or less. This strategy can be used to resolve a “nuisance value” claim without having to worry about Medicare issues.

Future Medical Benefits

  • A trial can also be used to limit liability for future medical benefits. If the arbitrator decides that certain future medical treatment is not necessary or is unrelated to an accident, that treatment will not need to be included in a Medicare set-aside.
  • There are different types of Medicare set-asides (evidence-based, legal zero, medical zero) that can be used to help balance Medicare liability with the cost effective resolution of a claim. It is important to select the right type of MSA for your case.
  • A Rated Age report can help reduce the amount of a Medicare set-aside to a significant degree; even a couple of years of reduced life expectancy can eliminate tens of thousands of dollars of future medical benefits from a Medicare set-aside.


  • If a Medicare set-aside is submitted to CMS for review, and the set-aside is significantly increased, consider a re-review or amended review. This is an appeals process to determine the proper amount of a Medicare set-aside.
  • Particularly with regard to an amended review, the savings available can be drastic.
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