Are hospitals required to bill private insurance before Medicare in case of accidents? (plan, doctor)

[Windwalker2]

A friend was visiting a home and tripped on a step she didn't see. She was bruised and badly sprained her ankle. The ER told her to provide the homeowners insurance info for the place where she fell, because of a Medicare requirement. It belongs to friends of her SIL and he did not want to ask for it. She needs follow up care and is afraid to see a doctor because of potential costs.

Is this a new Medicare requirement, that they are second payers to private liability insurance? My Mom broke bones many times in falls and no one ever demanded insurance info from the place where she fell.

I can see this being a nightmare for elderly people who tend to fall more and break bones. Also would be a problem in case of auto accidents.

[theatergypsy]

Yes, Federal law requires that all payment sources be exhausted before Medicare. Medicare is always the payor of last resort.

[Windwalker2]

When did this change?

Is it the responsibility of the injured person to get insurance information? If they can't get it, are they then financially responsible for all of their care?

[christina0001]

My understanding is that if your friend were going to file a claim against the homeowner's insurance, then that policy would need to be billed first. This is not a new regulation. But if your friend does not plan on filing a claim, it's a non-issue, and Medicare would be the first payor source (assuming that is your friend's primary insurance).

I would suggest your friend call during the week and speak to a billing manager at the hospital to confirm. I suspect the ER registration person might be misinterpreting Medicare regulations, assuming your friend isn't planning on filing a claim against the home owners insurance.

[Windwalker2]

I hope you are right about this. This makes sense but the more extreme interpretation doesn't.

[Ariadne22]

That would mean if I fall in my own home, my homeowner's would be responsible before Medicare?? Sounds like an overeager, overzealous newbie at the hospital admitting desk.

[Jo48]

My question is why did she go to an ER in the first place? A SPRAIN? You don't know how to treat a simple SPRAIN yourself? Thousands of dollars to go to an ER for something like this? No wonder, health care costs are out of control.

[Windwalker2]

Originally Posted by Jo48

My question is why did she go to an ER in the first place? A SPRAIN? You don't know how to treat a simple SPRAIN yourself? Thousands of dollars to go to an ER for something like this? No wonder, health care costs are out of control.

She's an older woman. She was badly bruised and cut. She landed on her hip. She was unable to get up without assistance. An improperly treated sprain, with separation of ligaments, can require surgery, which would have cost a lot more.

[Windwalker2]

Here are the two statutes cited by the hospital on the form given to my friend.
42 U.S.C 1395 y (b) 2
42 C.F. R. 411.20

Here is a readable commentary on this regulation.
CMA*||* Medicare Secondary Payer Program

I really think the hospital is interpreting this in their own way to get a higher payment than Medicare might authorize. I don't see the law saying that the hospital is to require the kind of form my friend was given, demanding information on the property owners insurance so as to bill them first. She has no intention of suing, so there won't be any settlement. I can see Medicare wanting reimbursement IF there is a settlement, but I don't see Medicare required to withhold payment initially.

Elderly people fall for many reasons and they are fragile and get hurt or even die. If property owner liability insurance companies get involved, they might force injured, sick people to go to court to prove the liability. I don't think that is the intent of the law.

[nightlysparrow]

Originally Posted by theatergypsy

Medicare is always the payor of last resort.

If the person has Medicaid, or if it is obtainable, that is the absolute payor of last resort.