Fix Medicare Secondary Payer System for Responsible Organizations Trying to Settle

Every year, an estimated 500,000 personal injury-related cases are settled in the United States, by far the largest area of civil litigation in the country. Tort cases, workers compensation claims and even auto accidents typically lead to a settlement where the liable party must pay for an individual’s medical expenses. While this process is usually relatively straightforward, that’s not always the case when Medicare beneficiaries are involved.

That’s because in cases where an injured party is covered by the Medicare program, the law recognizes that Medicare’s responsibility to pay for a beneficiary’s health care expenses is secondary to the party’s private insurer. This well-established policy is designed to ensure taxpayers don’t foot the bill to cover health care expenses for which another private payer is responsible.

However, the process by which Medicare recuperates payment for these claims — known as the Medicare Secondary Payer process — is broken, especially in situations where a beneficiary is covered by a Medicare Advantage or Part D plan. The problem is that settling parties have no way to find out in which Medicare plan the beneficiary participates and therefore cannot coordinate benefits or repay what is owed. And it is not from lack of trying, either.

For example, say a Medicare beneficiary enrolled in an MA plan has a slip and fall accident while shopping at a local business and is rushed to the hospital for a broken hip. The Medicare plan pays the hospital bills. However, a subsequent personal injury lawsuit results in a settlement including the medical costs.

How does the settling party repay a Medicare Advantage plan? The answer should come from the Centers for Medicare and Medicaid Services — the government agency that oversees the Medicare program — but CMS today will not tell the settling parties what MA plan a beneficiary is even in.

If that person had been covered by traditional Medicare, the Medicare Secondary Payer Act establishes a clear process for payment. But for individuals enrolled in MA plans — which cover 22.4 million Americans as of this year — there is no such process. Businesses wanting to do the right thing are left in the dark about how much they owe and to whom. The result: headaches all around.

It simply doesn’t have to be this way. Congress has an opportunity to make some common-sense reforms to the arcane Medicare Secondary Payer process to offer a simple and taxpayer-friendly solution to this problem. It requires more information sharing between CMS and settling parties — such as whether the beneficiary is enrolled in an MA or Part D plan along with the name and identity of the plan and dates of coverage.

That’s why we recently introduced H.R. 1375, the Provide Accurate Information Directly Act, which accomplishes this goal by requiring CMS to share needed information with third-party plans. With just one small legislative change, Congress can create a smoother, speedier and fairer claims process for all parties involved — a rare opportunity in a time of political division.

We encourage our colleagues to co-sponsor this legislation that will bring immediate tangible benefits to beneficiaries, businesses and most importantly — taxpayers.


Rep. Ron Kind (D) represents the 3rd District of Wisconsin, and Rep. Gus Bilirakis (R) represents the 12th District of Florida.

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