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Medicare Billing Rules

Billing Rules for Medicare

After an accident, health care providers and hospitals are empowered to seek reimbursement for their services out of any resulting personal injury settlement. When a Medicare beneficiary is hurt in an accident and receives treatment, hospitals and health care providers must submit their bills to the Centers for Medicare and Medicaid Services (CMS) for payment or file a claim against the injured party’s settlement proceeds. CMS has rules in place regulating when and how much hospitals and providers can bill, and when their claims must be withdrawn.

How They Bill

After treating the accident injuries, health care providers and hospitals must bill the liability insurance of the responsible party. After the hospital or provider files a lien, submits a bill to the insurer or discharges the plaintiff (the injured person filing a lawsuit) after providing services, the hospital or provider will have 120 days to decide to bill CMS directly or maintain their claim against the plaintiff- but not both. This 120-day is known as the “promptly period.”

Upon expiration of this period, claims asserted against the plaintiff must be reduced by procurement costs, such as attorney’s fees and litigation costs. These expenses are also deducted from the settlement’s total, with the adjusted settlement being the maximum recoverable amount.

Save the Date

Another important time frame regarding hospital’s and provider’s billing schemes is the “timely filing period.” The term of Medicare’s “timely filing” requirement is one calendar year from the date of service, after which liens against the plaintiff’s settlement must be withdrawn (with certain exceptions). Generally, claims against a liability settlement and all billing efforts to collect from the beneficiary must be terminated once the “timely filing period” ends.

Billing Medicare

If a hospital or provider submits a bill to Medicare, they are committed to the amount Medicare approves for payment. This limitation remains in place even if the bill is denied or the amount paid to the provider or hospital is refunded.

Actual Charges

Many hospitals and health care providers pay contracted rates to Medicare. This is sometimes noted on hospital bills where the cost of services rendered might be substantially higher than the amount Medicare is contracted to pay. In the event of a personal injury lawsuit, the hospital can claim the “actual charges” against the plaintiff regardless of what the contract with Medicare demands. The hospital thus has a real incentive to assert a lien, especially if they believe there is a strong case with a high-value settlement forthcoming.

Using the Rules in Your Favor

An experienced Sacramento personal injury lawyer will be able to help you navigate the complexities of filing a claim and dealing with insurance companies. Deadlines like the conclusion of the “timely filing” and “promptly period” can be used to your advantage as your attorney works to negotiate down the amounts claimed by hospitals and providers. In particularly long cases taking more than one year, an experienced attorney may even be able to reduce a hospital’s or provider’s liens to next to nothing or have them withdrawn outright.

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Sacramento Personal Injury Lawyer

I’m Ed Smith, a Personal Injury Lawyer in Sacramento. Have you or someone you love been injured in an accident? Do you need help filing a personal injury claim or dealing with insurance adjusters? Please reach out to me at (916) 921-6400 or (800) 404-5400 for compassionate, free and friendly advice with no obligation. I can also be reached online at

Since 1982, I have been serving the Sacramento and Greater California community, helping people injured in accidents and their families recover.

Have you ever wondered what people have to say about working with Sacramento personal injury lawyers? Visit my client reviews located on Avvo, Yelp, and Google.

My advocacy has earned me the recognition of the Million Dollar Forum. This group is reserved for trial lawyers with million-dollar verdicts and settlements.

You can obtain information about some of my Past Verdicts and Settlements and their dollar amounts posted to my website.

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