Coordination with Worker’s Compensation

300.6 - Coordination with Worker’s Compensation (Rev. 4, 10-01-01) Medicare may not pay for services that are payable under Workers’ Compensation (WC) laws. Where the Medicare cost-based HMO/CMP coordinates its own health organization with WC coverage, it will use the procedures developed by its own organization to identify and recover costs for services furnished to Medicare members. When the Medicare cost-based HMO/CMP does not coordinate benefits for its own organization, it must establish reasonable screening procedures to identify potential WC liability situations. If it is determined that Medicare has paid for items or services which can be or could have been paid for under WC, the Medicare payment constitutes an overpayment. All WC acts require that the employer furnish the employee with necessary medical and hospital services, medicines, transportation, apparatus, nursing care, and other necessary restorative items and services. For specific information regarding the WC plan of a particular governmental entity, contact the appropriate agency of the governmental entity. If payment for services cannot be made by WC because they were furnished by a source not authorized by WC, the services can be paid for by Medicare. The beneficiary is responsible for taking whatever action is necessary to obtain payment under WC where payment under that system can reasonably be expected (e.g., timely filing of a claim, furnishing all necessary information). If failure to take proper and timely action results in a loss of WC benefits, Medicare benefits are not payable to the extent that payment could reasonably have been expected under WC. NOTE: When failure to file a proper claim is due to mental or physical incapacity of the beneficiary, and the provider could not have known that WC was involved, this rule does not apply.