Conditional and Denial of Payments under the Medicare Secondary Payer Act

This presentation will discuss the factors that may result in Medicare seeking reimbursement associated with Ongoing Responsibility for Medical Reporting (ORM) and settlement reporting (i.e. TPOC reporting).

Additionally, there are times when Medicare may deny payment for treatment and argue the treatment should be paid under the non-group health plan based on ORM or TPOC reporting. Denial by Medicare may impact the claimant’s ability to obtain treatment where Medicare should in fact be the primary payer. This presentation will discuss these circumstances and factors to consider resolving this issue.

Three take aways:

· Understand role of ORM and TPOC reporting with Medicare Secondary Payer Act and Coordination of Benefits

· Recognize different types of denial of payment by Medicare

· Identify factors that may impact Medicare’s denial of payment