Violating the Medicare Secondary Payer Act Can Hurt Insurers’ Bottom Line


Not accounting for Medicare’s interest during workers’ compensation settlements can lead to shortfalls in insurers’ bank accounts.

Under the Medicare Secondary Payer Act (MSP), the Center for Medicare and Medicaid Services (CMS) has the right to seek reimbursement of medical expenses paid by Medicare, which the workers’ compensation carrier should have made. [1] The Act requires that insurers consider Medicare’s interest during claim settlement and reimburse the Center for expenses paid towards treatment of the Medicare beneficiary’s work related injury. Participants in a settlement who fail to adhere to the Act’s rules may find themselves accosted with fines and significant liens.

Developing a Medicare Set-Aside allocation can protect the parties from these fines. It also gives the parties a realistic projection of the claimant’s future medical cost and provides the opportunity to base settlement negotiations on this number.

[1] 42 U.S.C. §1395y (b)(2)(B)(i)(ii)(iii)