Terms:
Definitions:
Accident - An unintended occurrence outside the normal course of events which causes illness, injury or damage to a person or property.
Administrative Law Judge - A judge who works in the Office of Hearing and Appeals of the Social Security Administration.
Authorization - A document signed by the beneficiary or representative authorizing the release of Medicare claim information.
Automobile - any self-propelled land vehicle of a type that must be registered and licensed in the State in which it is owned.
Compromise - A settlement of differences by mutual consent or adjustment of matters in dispute by mutual concession; a negotiated settlement between parties who are in essentially equal bargaining positions, wherein neither party admits or concedes that he is entitled to less than he desires, but accepts less to effect the goal of ending the dispute. In a MSP situation under the Federal Claims Collection Act, a compromise represents the acceptance by HCFA or the regional office (RO) of less than the full debt owed to Medicare, when the amount of the full debt does not exceed $100,000, or by Central Office (CO) when the amount exceeds $100,000. An individual who accepts a compromise has no right to appeal the remaining debt.
Contractor - The Medicare office responsible for processing Medicare Part A (hospital, skilled nursing facility, home health agency, rehabilitation centers) and Medicare Part B (physician services) claims for Medicare recipients.
Fiduciary - A person in a position of trust with regard to the affairs of another, who has a duty to act primarily for the benefit of the other, with respect to a particular undertaking.
Final Payment Demand Letter - Letter sent to the attorney after receipt of settlement information advising Medicare's recovery amount.
Full Waiver - The relinquishing of an established right. In an MSP situation, it is the forgiveness of the party's obligation to satisfy Medicare's claim, in its entirety, if certain conditions are met.
Health Care Financing Administration (HCFA) - A branch of the Federal government which is responsible for assuring the adherence to federal rules and regulations pertaining to the Medicare program.
Judgment - The official and authentic decision of a court of justice upon the respective rights of the parties to an action submitted to it for determination.
Liability - Responsibility or fault for damages arising out of a specified accident/incident.
Liability Insurance - Insurance (including a self-insured plan) that provides payment based on legal liability for injury or illness or damages to property. It includes, but is not limited to, automobile liability insurance, uninsured motorist insurance, underinsured motorist insurance, homeowner’s liability insurance, malpractice insurance, product liability insurance, and general casualty insurance. It also includes payments under "wrongful death" statutes that provide payment for medical damages.
Liability Insurance Payment-- A payment by a liability insurer, including a payment to cover a deductible required by a liability insurer, by any individual, or other entity that possesses liability insurance or is covered by a self-insured plan.
Medical Payment (Med-Pay) - A payment made by an insurer intended specifically to pay for medical expenses without regard to the fault of any party to the accident. This is sometimes called Personal Injury Insurance (PIP). Med-Pay is a form of no-fault insurance. In these cases Medicare’s proportionate share of procurement costs are not deducted from this payment unless the claim was contested.
Medicare Recovery - Amount due Medicare to satisfy the Medicare claim.
Medicare Secondary Payer (MSP) - Refers to those situations in which Medicare does not have primary responsibility for paying the medical expenses of a Medicare beneficiary, because the beneficiary is entitled to other coverage which should pay primary health benefits.
No Fault Insurance - insurance that pays for medical expenses for injuries sustained on the property of premises of the insured, or in the use, occupancy , or operation of an automobile, regardless of who may have been responsible for causing the accident. This insurance includes, but is not limited to automobile, homeowner’s and commercial plans. It is sometimes called "medical payments coverage" (Med-Pay), personal injury protection" (PIP), or "medical expense coverage".
Partial Waiver - A decision by the Medicare program to relinquish the right to collect from a specific entity. A partial waiver is not to be confused with a compromise. It is different in that it does not arise from negotiation of offer, but under Section 1870(c) of the Act which provides the beneficiary the right to request waiver and Medicare the authority to grant or deny waiver, based on factual data. An individual may appeal a determination based on Section 1870(c) of the Act if the determination grants only partial waiver of a debt.
Payment Listing - List of all providers for which Medicare (A&B) has paid benefits relating to a specific accident/incident.
- Pre-Settlement Compromise - Is the same as a compromise, except that it takes place prior to settlement. Again, it should be noted that we, as a contractor, have no authority to enter into a pre-settlement compromise. If a beneficiary or their attorney wishes to discuss arrangements by which Medicare’s claim might be reduced prior to settlement, they should make their request in writing to us and we will forward it to the appropriate party at HCFA since only HCFA has that authority.
Procurement Costs - Attorney fees and other costs directly related to securing a settlement or judgment that are borne by the party against which Medicare seeks to recover.
Recovery - Proceeds obtained from a judgment or settlement through a law, formal judgment, or decree of a court. The establishment of a right existing in an individual through a law, formal judgment or decree of a court.
Settlement - An adjustment or agreement by which parties having a dispute between them reach or ascertain what each owes the other. In the MSP liability context, refers to a monetary amount from a liability insurer agreed to by a party in satisfaction of a liability dispute.
Subrogation - the substitution of one person or entity for another. Under the Medicare subrogation provision, the program is a claimant against the responsible party and the liability insurer, to the extent that Medicare has made payments to or on behalf of the beneficiary.
Third Party Payer - An insurance policy, plan, or program that is primary to Medicare.
Underinsured Motorist Insurance - insurance under which the policyholder’s level of protection against losses caused by another is extended to compensate for inadequate coverage in the other party’s policy or plan. This is included in the definition of liability insurance for Medicare purposes.
Uninsured Motorist Insurance - insurance under which the policyholder’s insurer will pay for damages caused by a motorist who has no automobile liability insurance or who carries less than the amount of insurance required by law, or is underinsured. This is included in the definition of liability insurance for Medicare purposes.
Waiver - The relinquishing of an established right. In an MSP situation, it is the forgiveness of the party's obligation to satisfy Medicare's claim, in whole or in part, if certain conditions are met.
Wrongful Death - A death caused by a wrongful act, neglect, or fault, as seen in some liability situations.