Action if a Liability Insurance Payment Has Been Made to the Provider,

40.5 – Action if a Liability Insurance Payment Has Been Made to the Provider, Physician, or Other Supplier Who Accepted Medicare Assignment (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) If a A/B MACs and DME MACs discovers that Medicare paid primary benefits and payment was also made by a liability/no-fault insurer, it recovers the excess Medicare benefits in accordance with Chapter 3 of the Medicare Financial Management Manual. Section 90 of that manual states when a provider, physician, or other supplier is liable for refunding the primary Medicare payments. The beneficiary is liable in all other situations. Upon receipt of information that a liability/no-fault insurer paid a provider, physician, or other supplier for services previously paid for by Medicare, the A/B MACs and DME MACs determines the amount of Medicare secondary benefits payable on the claim. It recoups from the provider, physician, or other supplier any portion of the amount Medicare paid in excess of the amount of Medicare secondary benefits payable, subject to the overpayment recovery threshold (currently $25) in Pub. 100-06, Medicare Financial Management Manual, Chapter 4, § 10. Where no Medicare secondary benefits are payable, the A/B MACs and DME MACs recover the amount of the Medicare payment. The provider, physician, or other supplier may keep the full liability/no-fault insurance payment, but may not charge the beneficiary any amount for the services and must return any deductible and coinsurance amounts paid by or on behalf of the beneficiary. (See Pub. 100-06, Medicare Financial Management Manual, Chapter 3, § 70, where the provider, physician, or other supplier did not file a proper claim).