Medicare/Secondary Payer

[Guest tonjer]

We have a client that has received notification from a collection agency seeking reimbursement because Medicare paid primary when it should have paid secondary. The services were provided 7 years ago, however, the client's tpa was provided with the notice within the 3 year statute of limitations. Is there anyway for the client to get off the hook because the client (the employer) itself did not receive notice within the appropriate statute of limitations period?

[Sandra Pearce]

These notices are sent out by Medicare to employers. In the ten years our health plan has been in existence the plan itself or the TPA has never received a notice, only the employer companies participating in the plan. If you look further you will probably find that the original questionnaire was sent to the employer and the employer probably forwarded to the TPA.

[Guest tonjer]

This was in fact the first notice received by the Client. The TPA has acknowledged that it has in fact received the prior notice and simply did not forward it on.

[PhilB]

At some point the employer probably completed a IRS/SSA/CMS Data Match request that prompted the notice of overpayment after the information was digested by CMS. I would just give them a call. They're usually pretty accomodating in these situations if you explain the circumstances and don't ignore their letters. I've completed a slew of them this year requesting information back to plan year 1998, so I don't know if the 3 year limitation has an application here or not.

[Mary C]

The three year limit is only on brand new, first time sent reimbursement requests. If the request had been sent to someone before, whether its a TPA, Union, plant location, home office, insurer or whoever, the three year limit does not apply. Its now considered a past due debt and the collection agencies involved are NOT accommodating or considerate.

[jsb]

I think both MaryC and PhilB have hit it on the head...collection agencies will give you no quarter but the CMS may be able to help you out. Since it would have been CMS sending you to collection, only they can stop it.

Can the client get off the hook? No, probably not. If client should have paid primary, it should have paid primary. But I'd sure be looking to the TPA for indemnification for charges, penalties or other costs, especially since the TPA has already admitted some culpability for not forwarding notices. And if the TPA's inaction caused client to lose its ability to contest the charges to CMS, then the TPA should pay that too.

If the TPA won't step up to the plate for their error, you need a new TPA.