How to Fix Medicare Denials When You Have a Previous Workers' Compensation Claim in Texas

Updated on May 27, 2020
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Sara has been handling Medicare issues regarding Workers' Compensation for over 7 years. After a lot of trial and error she has a solution.

But My Workers' Comp Claim Is Closed!

I receive multiple calls a day from people who have the same issue. They are on Medicare and trying to treat at the doctor's office, have surgery, or get approved for services such as Hospice. Out of nowhere they are told a shocking statement:

"We show that you have an open workers' compensation claim that is your primary coverage. You have to call Medicare and have it closed before you can get approved for treatment."

Getting Nowhere Fast

They Call Medicare: Medicare confirms they have an open workers' compensation claim on their file. They are then told they must call the insurance company and have them fax proof of the claim closure date.

Although Frustrating, That Seems Easy Enough. Right?

In every state except for Texas, this can usually be done. However, in Texas, in most cases it can't.

Understanding Texas Workers' Comp Laws

  • Texas Labor Code 408.055(b) and 408.021 (d) prohibits the settlement of medical benefits for workers' compensation claims.
  • Texas Workers' Compensation Act allows injured employees to receive all healthcare reasonably related to the compensable injury, and these benefits may not be limited or ended by an agreement or settlement.

Understanding Medicare vs. Workers' Compensation

Section 111 Mandatory Reporting: Medicare requires workers' compensation insurance carriers to report workers' compensation claims that meet the following criteria:

Regardless of the initial date of injury, all workers' compensation claims that are active (open) anytime after 1/1/2010 that have ANY of the following:

  1. More than $750 total medical benefits paid.
  2. ANY payments/reimbursements made to the claimant.
  3. More than 7 days of lost time.

In the state of Texas, workers' compensation claims that are active anytime after 1/1/2010, that meet the reporting criteria, will show as open and primary for the rest of the person's life. This remains true even if they are no longer treating for the injury.

What Am I Supposed To Do?!

The question is always: "If I can't close my claim, how am I supposed to get treatment?" This has been an ongoing debate for the countless number of people experiencing this issue, and the attorneys and employers trying to help them.

Most everyone puts the responsibility onto Medicare, assuming that they have an issue that needs to be corrected. This was displayed on July 31, 2014 when The Texas Department of Insurance, Division of Workers' Compensation Commissioner Rod Bordelon wrote a letter to the CMS Administrator, along with the Texas State Congressional Delegation.

The letter pleaded with CMS, asking them for a solution to the denials, but unfortunately the denials and frustration continued.

Misguided Blame

After several years of battling back and forth with Medicare, I discovered something that is vastly overlooked. The fault is not with Medicare, but with the providers.

Medicare has very specific billing requirements that all providers must follow when submitting bills for reimbursement. These are outlined in the Medicare Billing Manual.

Not Work-Related
Workers' Comp
Treating for a Work Injury
Must be Related to the WC Injury
Not Work-Related
Must identify services are not related to the open MSP Record
Workers' Comp
Treating for a Work Injury

How to Submit Bills Unrelated to the Open MSP Accident Record

  1. In the Remarks field, indicate: "Services not related to active MSP 15 (workers' comp) accident record."
  2. Do not report Occurrence Code 04 or WC-related diagnosis codes on the claim. (You may need to contact the workers' compensation insurer to verify the compensable injury diagnosis codes to ensure you are not using them on your claim.)

What About Other States?

Each state has its own laws in regards to when workers' compensation claims can be closed. However, regardless of the state, if you are dealing with a similar issue these billing guidelines are not Texas-specific. They can be used in any instance where the MSP record is still active.

If you are handling other types of insurance:

  • You must change the MSP number on Step 1 appropriately.
  • A different occurrence code would apply on Step 2.

Things Texas Providers Should Avoid

  1. Telling the beneficiary to contact Medicare and have their claim closed before treatment can be rendered.
  2. Holding beneficiaries finically responsible, including turning them into collections for charges denied by Medicare.
  3. Refusing to file an appeal following Medicare billing guidelines.

The beneficiary is not financially responsible for charges or appeals when the provider has made a billing error. Failure to identify the primary payer correctly in accordance with Medicare Guidelines, results in denials that are fault of the provider, NOT the beneficiary.

The Fight for Medicare Beneficiaries

The good news is, if you are having this issue, you are not responsible for the charges. It can however be difficult to get some providers to correct their billing. In my experience, I can tell you that calling Medicare will not get your problem solved. The billing must be addressed with every provider/facility you treat with.

A Story of My Experience

Several years ago, I had a family call me that had this issue with their mother. She was very ill with cancer and was trying to get into Hospice. She was previously a food service worker that had cut her finger while on the job. She hadn't treated for the injury in more than 10 years. The Hospice facility did not understand Texas laws, and how to bill to Medicare in this situation, so they denied her entry. She died in an unnecessary amount of pain and was never allowed into Hospice. The family was devastated.

This issue greatly effects the lives of Medicare beneficiaries and often their families. I can't begin to estimate the number of people I have spoken with and assisted over the years that were in this situation.

I wrote this article to help inform others that there is a solution. Please help me spread this information so that others can find the answers they need.

This article is accurate and true to the best of the author’s knowledge. Content is for informational or entertainment purposes only and does not substitute for personal counsel or professional advice in business, financial, legal, or technical matters.

© 2019 Sara Magee


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