Reminder: Conditional Payment Letters From CMS Do Not Apply to Medicare Advantage Plans and Medicare


According to current data from CMS, over 36 percent of Medicare beneficiaries are enrolled in Medicare Advantage Plans and over 41 percent of Medicare beneficiaries are enrolled in Medicare Prescription Drug Plans. As such, there is a high probability when settling a case with a Medicare beneficiary that the claimant is enrolled in either a Medicare Advantage Plan or a Medicare Prescription Drug Plan. It is important to remember that conditional payment letters from CMS do not include information on Medicare Advantage/Prescription Drug Plan liens. Instead, Medicare Advantage/Prescription Drug Plans must be contacted separately to obtain lien information. Often, when a claimant is enrolled in a Medicare Advantage Plan, the parties will receive a $0.00 conditional payment letter from CMS when a Medicare Advantage Plan paid for the claimant’s treatment instead. Lien research should continue until Medicare Advantage/Prescription Drug Plan liens are discovered and resolved.

In recent years, an increasing number of federal courts have held that Medicare Advantage/Prescription Drug Plans can assert a private cause of action against primary payers and recover double damages if their liens are not resolved, even if the parties have agreed that the claimant will be responsible for repayment. As such, we recommend ensuring that any Medicare Advantage/Prescription Drug Plan liens are resolved when the claimant is enrolled in a plan. If you would like any assistance in determining whether a claimant is enrolled in a plan and resolving any liens, please let us know and we will be happy to help.

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