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Employers

Employer Bulletin

State Agencies & Local Health Employers
Vol. 19, No. 10
June 27, 2002

How to Handle a Formal Notification of Claims Payable from a Medicare Intermediary or Threat from Collection Agency

All employers should be aware of the Medicare Data Match process from previous Employer Bulletins:

Vol. 16, No. 13 dated September 20, 1999 (attachment updated 11/08/2002)
Vol. 17, No. 5 dated March 8, 2000
Vol. 18, No. 13 dated August 16, 2001

These bulletins are available on the Department of Employee Trust Funds (ETF) Internet site at etf.wi.gov and navigating to the Employer Bulletins section through the "Employer" button.

Medicare Data Match Project is a federal program that requires employers and health care plans to provide information about specific current or former employees covered under the employer's health plan. Medicare, administered by the Health Care Financing Administration (HCFA), may have requested information from you regarding the health insurance coverage and employment status of specific current or former employees. If Medicare paid a claim(s) as the primary carrier, when in fact, the employer's group health plan was the primary carrier, the plan is responsible for reimbursing Medicare for the claim(s).

Some employers have recently received collection notices issued by or at the direction of HCFA for repayment of claims. In certain situations, plans may have already responded to HCFA that they are not responsible for payment under the terms of their contract. In other situations, the plan may not have been specific enough in their explanation, resulting in Medicare pursuing the employer for repayment of a benefit paid.

Because of this recent development, ETF strongly recommends keeping full documentation of any correspondence with HCFA regarding Medicare data match requests. It is the employer's responsibility to keep complete records, including copies of the health plan's response to Medicare.

Medicare does have the right under Federal Law to collect the money paid in error from the employer. However, it is our view that the employer should not have to pay the amount owed if the matter is properly referred to and handled by the appropriate health plan. Reasons the employer should not have to pay include:

  • The claim has already been paid
  • The claim is the responsibility of the plan
  • Medicare is the primary payer

The plans may have already paid Medicare the money or responded that the claim is not under the terms of their contract. You should have documentation of any Plan response to Medicare. ETF suggests that you insist the Plans provide copies to you as the Employer with any response they make to Medicare. You should make sure the response sufficiently explains the Plan's position regarding any claims the plan denies under terms of their contract.

If you receive a letter from a Medicare Intermediary or a Collection Agency on behalf of Medicare indicating that money is due and/or that money will be taken from your agency's Federal funding, please follow these steps:

  1. Verify that the employee(s) was identified to HCFA through a data match request and review your records concerning each individual to make sure that you have all the documentation and copies of the documentation from the Plan(s). Plans are to handle the repayment requests and the HCFA expects the Plans to follow their procedures when responding.
  2. Contact your legal counsel for assistance.
  3. Prepare a letter to the requestor using either of the attached Sample Letters.
  4. Contact the specific Plan representative to determine the current Coordination of Benefits person, then send a copy of the documents to that person.
  5. Follow up with the Health Plan contact if the matter is not resolved by the Plan in a timely manner.

Employee Trust Funds has no specific role in this process. However, we may be able to offer assistance. Questions about collection notices and how to handle them can be directed to the Employer Communication Center at (608) 264-7900.


Sample Letter A

I am writing in regard to Debt Identification Number ______________, which is addressed in the enclosed copy of your letter, dated ________________________.

I challenge the assertion that the (Employer Name) owes HCFA $ . It is my belief that all claims are payable, or have been paid, by (Health Plan Name) (the HMO with whom (employee's name) had health insurance coverage), or the appropriate carrier; or, the claims are not covered as a primary benefit under the State of Wisconsin group health plan.

(Name of individual and Health Plan), is processing all appropriate claims. You may contact (him/her) at:

(Health Plan Contact Name
Plan Name
Plan Address
)

(Name of Plan Contact)'s phone number is (plan contact's phone number). If you have any questions, please contact (Plan contact's name); otherwise, she/he will respond, as soon as is practicable, to specific requirements in your (date) letter.

Sincerely,

Enclosure

cc: (Plan Contact Name/Plan)
Bill Kox, Dept. of Employee Trust Funds


Sample Letter B

 

On (date), we received a Formal Notification in regard to Debtor ID# __________. A copy of the Formal Notification dated (date) is enclosed.

Upon calling your office, we were advised that this Debtor ID# related to Medicare payments on behalf of (employee's name).

This letter is to advise that the (employer name) did not receive the first notice regarding this claim from HCFA as part of the Medicare Data Match process. Also, (employer name) did not receive the second notice of such claim, which is generally sent one year after the first notice, providing the employer an opportunity to respond with 30 days.

Therefore, I am requesting that you provide to (employer name) any and all documentation on this claim including the name of the Medicare Intermediary. This documentation must contain all of the information that would have been originally provided by HCFA when submitting the first notice to (employer name). The documentation can be sent to:

(Your name and address)

I challenge the assertion that (employer name) owes HCFA $___________. It is my belief that all claims are payable, or have been paid, by (Health Plan) (the HMO with whom (employee name) had health insurance coverage), or the appropriate carrier; or, the claims are not covered as a primary benefit under the State of Wisconsin group health plan.

Should you want to contact (health plan), (health plan contact name), is handling this situation. Mr./Ms. (name)'s address is (address of health plan).

Sincerely,

Enclosure

cc: (Health Plan contact name and plan)
Bill Kox, Department of Employee Trust Funds
US Department of Treasury–FMS

 

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