If you have brought a claim for lump sum compensation arising from a physical or psychological injury sustained in the course of your employment, you may need to know about Medicare and how they are involved in your claim. So let’s dive in!
When does Medicare become involved?
If you receive a lump sum compensation amount over $5,000 you will need to repay Medicare for any treatment or care costs that have been paid by Medicare on your behalf that relates to your injury. This could be the amount Medicare paid for a radiology scan or a doctor’s appointment you attended. If this is you, then there are a few Medicare forms you will need to fill out at some point during your claim. These forms might be sent to you from Medicare directly, by your Workers Compensation Insurer or your lawyer.
So what do you need to do when you get these forms?
If you have a personal injury lawyer assisting you with your compensation claim, they will send you a Medicare Compensation Recovery Third party authority form. This form allows your lawyer to correspond with Medicare on your behalf and request a Notice of Charge from Medicare to determine what your payback will be.
After your lawyer has requested a Notice of Charge, you will be sent a Medicare History Statement to fill out. This form will list all benefits Medicare has paid since the date of your injury.
Filling out the Medicare History Statement
To complete this form you will need to tick the ‘Yes’ or ‘No’ box next to every item on that list. You should only tick ‘Yes’ next to an item that is treatment related to your injury. If you are uncertain as to whether an item is treatment for your injury, it is best to speak to your lawyer or contact the treatment provider to check as soon as possible as the forms must be sent back to Medicare within 28 days. There is also limited information on these forms, and it is not always easy to understand what an item is for. If you have kept records about your injury, then any receipts from your treating doctors should state whether a Medicare benefit was received.
Once you have filled out the forms, you will need to send it back to your lawyer who will send it to Medicare to generate a Notice of Charge. If the forms are not back to Medicare within 28 days, you will receive a deemed Notice of Charge that says all services on the history statement are treatment that relates to your injury.
It is important to comply with these timeframes as the total of the Notice of Charge is the amount that Medicare will recover from you out of the settlement sum. If the Notice of Charge is deemed or expired before your matter settles, then you will need a new one.
If you have a valid Notice of Charge when your matter settles, then the Insurer will pay Medicare the amount on the Notice of Charge within 28 days of judgment or settlement. You don’t need to worry about this as the Insurer will pay it before they pay you the rest of your settlement sum.
What happens if I have received benefits from Medicare and my case settles without a valid Notice of Charge?
If there is no Charge or it has expired, the Insurer will pay 10% of the settlement sum as an advance payment to Medicare. For example, if the total amount of compensation you are getting is $500,000 then the advance payment is $50,000. This $50,000 sum will be held by Medicare until a Notice of Charge is generated.
At the time of settlement, the Insurer will notify Medicare that your matter has settled without a valid Notice of Charge. You will then receive a Medicare History Statement to fill out and you can follow the same steps listed under the heading “Filling out the Medicare History Statement” above.
If Medicare does not generate a Notice of Charge within 3 months of being notified of settlement (which can happen due to delays within Medicare), then Medicare is required to reimburse you the full 10% advance payment.
If Medicare do generate a Notice of Charge within 3 months, then Medicare will reimburse you any surplus from the advance payment. The Insurer should then be asked to reimburse you the amount of the Notice of Charge as Medicare is a treatment expense. If the Charge is more than the 10% advance payment, Medicare will issue you a Statement of Account advising of the outstanding amount. Your lawyer will send this to the Insurer asking that they attend to payment of the Statement of Account.
In the end you should get the full settlement amount back, but at separate times.
What form do I fill out if I have not received a benefit from Medicare for treatment or I have not received any more benefits since the last Notice of Charge expired?
If this is you, then you can complete the Medicare Compensation Recovery Section 23A Statement form to avoid the advance payment. This form declares that you have either never received any Medicare benefits or have not received any further benefits or care costs from Medicare since your last Notice of Charge expired.
If you are unsure about whether you have received a benefit from Medicare for treatment for your injury, you can check your last 3 years of Medicare benefits through either the Medicare App or MyGov if Medicare is linked as a service.
What should you do?
The Medicare process can be confusing, so it is important you contact a personal injury lawyer that has experience in workers compensation claims. If you have any queries regarding bringing a claim for lump sum compensation or Medicare’s involvement in your claim, give us a call on 1300 026 875 or contact us via our website – www.bourkelegal.com.