Billing Medicare And Medicaid For Patients With Injury Claims

When your injured patient is covered by Medicare or Medicaid (Oregon Medical Assistance Program), you may be inclined to bill another paying source which might be available. It is important to be aware of the rules effecting who you may bill, bow much you may bill and when you may bill.

This article gives an overview of the potential payers for treatment of accident-related injuries and reviews sonic of the rules involved when your patient has Medicare or Medicaid coverage. You may want to pass this article along to your billing office manager.

The first payment source when billing for accident-related injuries is Personal Injury Protection (PIP) coverage on the car your patient was in at the time of the accident. As explained in our Summer 1996 Medical Legal Journal (Vol. 1), all auto insurance policies in Oregon must provide a minimum of $10,000 no-fault medical coverage for up to one year after the accident. For more details on PIP, see that article or call our office and ask for Julia Lincharger-Taylor.

If PIP benefits are not available or have expired, your next option is to Bill your patient’s health insurance, which may include Medicare or Medicaid. Some medical providers are reluctant to hill the government programs, since they pay on a reduced fee schedule, and their payment is final. It seems better economic sense to wait to get paid in full by the “at fault” (liability) insurance carrier.

You may ask: May we regard Medicare/Medicaid payments as partial payments and bill the patients for the full balance? Or you may wonder: May we reimburse Medicare/Medicaid after seeking full payment from the liability insurer or settlement?

As legal counsel monitoring the medical expenses of hundreds of injured accident victims each year, we have seen these approaches. Believe me, we share your frustration with the increasing complexity of public and private medical insurance payment systems and regulations. So, here’s a summary of some of the rules for billing public payers for treatment of patients with a personal injury claim.



If you are a participating supplier or have accepted assignment from Medicare, you must first attempt to determine if there are potential primary payers other than the liability insurer – such as PIP (in Oregon), automobile “no-fault med-pay” (in California) or employer group health plan. These must be billed before Medicare. Medicare benefits are secondary to these coverages, so they will not pay until these resources have been exhausted.

Even though Medicare is also “secondary” to liability insurance, medical services do not lose their identity as Medicare-covered services. Where there is liability insurance coverage, Medicare pays benefits conditionally, then recovers their payments. When the liability settlement is made, their lien is primary to all, including outstanding medical balances, other insurance liens, welfare liens and the patient.

Medicare does allow providers to seek payment first from the liability insurer if payment is expected within the 120-day “Prompt Pay Period.” The 120 days count from the date of service or discharge. If the provider has reason to believe the liability insurer will not pay within this period and/or the liability insurer does not pay within the 120 day period, they MAY bill Medicare. However, they are not required to do so.

Providers cannot bill Medicare AND pursue liability money. It’s one or the other. When a provider bills Medicare, they must withdraw or modify claims against the liability insurer or liens placed on the settlement. These are limited to the patient’s deductibles and/or coinsurance. Medicare timely filing limitations continue to apply. So, if the liability payment takes too long, you could go beyond Medicare’s filing limitation and risk losing out all around.

You can also lose out if the liability settlement amount is not enough to satisfy the Medicare lien and pay remaining liens and balances. Medicare will not accept claims submitted after settlement, even if it is still within the timely claim filing period. AND, YOU CANNOT THEN BILL THE PATIENT!

After billing Medicare, you may not bill your patient for Medicare covered services, except to collect deductibles and co-insurance. Therefore, you may not bill your patient for the “excess” over the Medicare allowance for covered services after your patient receives liability funds.

Medicare also does not allow you to reimburse them and then seek payment in full from the liability carrier or from your patient after an injury award or settlement.


Medicaid provides health coverage for low income people through Oregon Health Plan (OHP) and Oregon Medical Assistance Programs (OMAP). Medicaid rules apply, even when coverage is provided through contracting payers, such as FamilyCare, Medford Clinic, P.C., Care Oregon, Mid Rogue IPA, etc. There may be additional rules pertaining to each specific plan.

As with Medicare, providers must first seek payment from primary sources, i.e. PIP, med-pay or group health insurance. When benefits from these payers have been exhausted, then providers can bill Medicaid. No matter which Medical Assistance Program (MAP) payer applies, claims must be submitted within 12 months from the date of service.

Providers should determine whether the patient has MAP coverage. Billing a covered patient directly is only allowed in certain circumstances. If you bill a patient you didn’t know was covered, your efforts to find out whether the patient was covered must be documented.

In cases involving liability, providers may bill the liability insurer, place a lien against the settlement OR bill the MAP. You may not place a lien against the settlement AND bill the MAP. However, you may withdraw the lien and THEN bill the MAP within 12 months of the date of service.

If you bill the MAP, you must accept their payment as payment in full. As with Medicare, you may not return the payment made by the Medical Assistance Program in order to seek payment from a liability settlement. All benefits paid by OMAP and the MAP become a lien against the patient’s recovery.

Closing Remarks

We hope this article has helped clarify some Medicare and Medicaid rules regarding personal injury patients.

Medicaid patients are the lowest income population in our state. Many Medicare patients also lack resources to pay the full medical fees required for their treatment.

As in other areas of insurance benefits, personal injury settlements are more difficult to obtain and payments are lower than in the past. By the time Medicare and Medicaid liens, income assistance liens and any fees and expenses have been paid, the injured party’s recovery has been significantly reduced. This is true in all but the best of cases.

The worst case scenario is when a provider has held off billing Medicaid and/or Medicaid beyond the claim filing period and the liability insurer refuses to settle or pays only minimal benefits. The provider then risks receiving no payment, or a reduction greater than Medicaid and/or Medicare payments! This is because both do not allow providers to bill patients directly.

So, by accepting Medicare and/or Medicaid payments, you are doing your part to help that portion of our population that is the least protected. The Medicare/Medicaid liens still come out of your patients’ injury claim dollars. However, these liens are in proportion to their recovery.

Still have doubts or questions? Please call us and ask for Julia. Let’s work together and find the best direction when you have a decision to make on whether to bill Medicare or Medicaid.

This article was prepared by Robert L. Chapman