Episode #97: CMS Reporting And Medicare Liens For Liability Claims

A “quick” injury claim can turn into a compliance puzzle the moment Medicare or Medicaid enters the picture and if you miss it, the consequences can be expensive. We get practical about CMS, Medicare Secondary Payer rules, and what adjusters actually need to do on day one so a settlement does not blow up later.

We walk through the Big Five identifiers we ask claimants for, why people understandably get suspicious, and how to explain the request without sounding like a scammer or hiding behind acronyms. Then we translate the jargon: Section 111 reporting, conditional payments, Medicare liens, Medicaid liens, and what “Responsible Reporting Entity” really means when carriers use vendors and automated reporting behind the scenes.

From there, we talk settlement reality. Why you may need to wait for a conditional payment letter and a final demand, how the $750 small settlement provision fits in, and why these steps feel like a delay tactic to the average person even when you are trying to close fast. We also cover risk controls like paying first and disputing later, using hold harmless and indemnification language when attorneys push back, and protecting PII so your file stays clean.

If you work property, auto, GL, workers’ comp, or liability claims, this is the kind of “unseen” process that can make or break a smooth close. Subscribe, share with an adjuster friend, and leave a review with the toughest Medicare lien question you have right now.

For more insights, you might consider a career in liability adjusting or if you're searching for reliable adjusting services, visit Auten Claims Management.

To explore more about Chantal Roberts and her contributions to the industry, visit CMR Consulting.

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Transcript

Welcome And Why This Matters

William Auten 0:06

Hello, I'm Bill Aughton of Autin Claims Management.

Chantal Roberts 0:09

I'm Chantel Roberts of CMR Consulting, and welcome to the Art of Adjusting Podcast.

William Auten 0:14

Today we're going to talk about life as an insurance adjuster from the perspective of property, auto, liability, or workers' compensation adjusters. Our goal is to bring interesting topics in the world of claims adjusting to people who are working as an adjuster now and to people who are considering a career as a claims adjuster. Good morning.

Chantal Roberts 0:33

Good morning.

William Auten 0:34

How are you today?

Chantal Roberts 0:36

I am having a day. How are you?

William Auten 0:38

I'm having another day too. It's it's this is fantastic.

Chantal Roberts 0:42

I love it when we're having days together.

William Auten 0:44

Yeah, yeah. As long as the heat, the feet hit the floor, uh, things are good.

Chantal Roberts 0:48

Man, I tell you what, uh, yeah, it was it was very good. My um husband let me sleep in today, and I woke up about an hour ago and I'm like, crap, I gotta go. I gotta podcast to do.

William Auten 1:02

Rush, rush. We're on a tight schedule here, Chanto.

Chantal Roberts 1:05

I know, right? I know. It's it's it's terrible. Uh sleeping princess, such that I am, you know, eating bonbons all day long, just waiting to do a podcast, uh, which is what we're doing today. And we're gonna be talking about a topic that may not interest some adjusters, uh, like the on the property side of things, but I think that you should still stick around, listen to it. We'll try to make it interesting. We are talking about the government, so there's only so much we can do to keep it interesting. Yeah, but but um we're gonna be talking about CMS. Uh that's the center of um oh, medical, Medicaid, Medicare um services, center of Medicare Services, I think.

William Auten 1:55

CMS centers for Medicare and Medicaid Services.

Chantal Roberts 1:58

Yes. Um, so we're talking about Medicare, Medicaid, liens, um, subrogations and liability and uh essentially what these adjusters, usually liability adjusters, need to know, but I want the property damage adjusters to sit up and pay attention in case y'all ever like switch lines, which I always encourage you to do, so you can become a multi-lined adjuster and become even more indispensable as you are.

William Auten 2:30

It's important for adjusters to know this, but I I think it's equally as important for injured people to understand this too.

Chantal Roberts 2:38

So I absolutely agree with that.

William Auten 2:41

One thing you're gonna kick things off with is this big five. I need to know what the big five is.

Chantal Roberts 2:45

Yes, I am, but and and while we're talking about it, uh the injured person to know about it. Agents need to know about it, uh, because they might get called by their insureds going, like, why does this adjuster want to know all of my business? And attorneys need to know this because when I was a liability adjuster, I got a lot of pushback from attorneys. And there's there's

CMS Basics And The Big Five

Chantal Roberts 3:10

some good reasons why we are asking these questions. Okay, so remember to like, comment, subscribe, share with all of your friends, especially because this is like really important. So we're gonna start off with some spoiler alerts. What the big five is. Okay, so the big five is something that a an adjuster needs to know about the claimant essentially right off the bat. And it's one of the first questions that we as liability adjusters are going to be asking the claimant. It is your name, your full name. Uh and I always called it your name, rank, serial number kind of deal. Your full name, your date of birth, your um uh see, now you're catching me like all off guard because I'm like going to the case.

William Auten 3:57

Now I know now I know what it is. So I can I can receive it. Your name, your name of birth, address, phone number, date of birth, social security number. Yes.

Chantal Roberts 4:07

Uh and and and the reason is these are your big fives. Okay, your name, date of birth, gender, gender, social security number, or partial um Medicare identification number, if you have that, yeah, and then um address whatever. These are your big five. These are the things that identify you. And the reason I say that agents need to know this, attorneys need to know this, uh, claimants, like you said, uh the the injured person needs to know this, is because the adjuster is going to be asking you this. And some random person is gonna be calling you saying, Hey, can you give me your uh date of birth, your driver's license number, your social security number, your Medicare number if you have it, you know, any of that kind of stuff. And we all go to our uh uncle who lives in Nigeria, who um is gonna leave us all of his money. All we got to do is give him the same information along with our bank account number, right? Right. That's the first thing we think of. And and so you're going to understand that this random person is just giving you a call after you've had this accident. They say that they're with the insurance company. You don't know. So, as an adjuster, of course, what I always said is like, look, this is this is what I need. I'm gonna need it, it's called the big five. Uh, this is why I need it. I need it because I have to run you through the Medicare services, the CMS services. And um, the the reason why I have to do this is we'll get into it just a minute. But if you're not comfortable giving all of that information to me, know that I'm gonna send you a letter that explains all of this. And still, some people are not comfortable giving their social security numbers out with everything that's going on nowadays, especially nowadays. I mean, they can clone your voice, right?

William Auten 6:22

Right.

Chantal Roberts 6:23

And um so you can even give a partial social, but it's not the last four, it's the last five.

William Auten 6:32

Five, yeah.

Chantal Roberts 6:32

I don't know why the government likes five, but they do. They they like five. It's it's a thing with the government that you know you we would probably get 555 pages if we asked them why. I don't know. I'm just saying it.

William Auten 6:46

It's funny because we have um we we request medical records with standard authorizations, and uh, on those authorizations, a lot of attorneys will leave the social security number off. And a lot of the healthcare providers will not respond if it's not on there. Right. So some attorneys have opted for the last four, and that narrows the pool down, but there's still some sticklers out there, these um hospitals, whatever clinics, that they just won't release it unless it's the full social. And we go back to the attorney and they say, Well, that's not true. And okay. Oh, wait, that's here's the letter they sent me. Uh yeah, yeah, yeah. So it it is, you know, there's a couple reasons why we have to get that information, is my point.

Chantal Roberts 7:39

Absolutely. I mean, it we start off. Let's let's take a step back and and start off with why we need it since we've already teased. This is the spoiler, this is the answer. Right there, the first five minutes. Woo! So now don't turn us off. We're we're gonna keep on going, telling you why, because that's that's the important part, because this is the important part that the that you need to know to be able to explain to the um attorney and to the claimant and and to and even to the agent, because again, a lot of times as adjusters, we're not the ones being trusted. You know, we're not the ones in town. They uh, you know, the insured may go over to the agent's office if there is still an office there. Okay, so um what happens is you get into a car accident or you trip and fall and you have some kind of accident, right? Um, or you slip and fall, or whatever. And the um adjuster, the insurance company has to prove that you as a claimant are not a Medicare or Medicaid recipient. And you're like, I'm 35. I'm like, yeah. And this is where the attorneys come in. Um, so attorneys that are listening, you'll go, my client's 35. And I'm like, yeah, don't care. Doesn't matter, do not, do not care. Um, and you can be a little bit more polite, adjusters, than than I ever was with my attorneys, but I would just go, don't care, do not care. You can be three years old, and I want to know what your um social security number is, because because the fine, and this is where um we get some teeth, because uh there is a lien, the government automatically has a lien on the payments that you make to a claimant or whatever, if they have made payments, and this was the subrogation part of it, right? And it's called like that super lien. And back in the day, uh when I first started, and Bill, probably when you first started, I mean, we knew about it, you know, but like nobody wanted to bother the government.

William Auten 10:01

It was it was not formalized like it is today.

Chantal Roberts 10:04

Exactly. We knew that there was a lien.

William Auten 10:09

Yeah, we would um there was a process, but I think we usually left the attorneys to go find it.

Chantal Roberts 10:18

Um see, so that that is exactly it. And the attorneys, God bless their hearts, bless their hearts, didn't really do anything about it. They didn't repay the government, and the government said, yeah, no, that's not gonna work for us anymore. So we're gonna need you to repay us. Okay. And so they formalized all of this. And so what they did was um they said, yeah, if you don't repay us, it is going to be a thousand dollars a day fine. Per claim per claim a day, and we don't care if we get it from the attorney or the insurance company or the

Why Adjusters Must Ask For PII

Chantal Roberts 11:05

third-party administrator, or well, the those those fines are actually for the insurer for the responsible reporting entity, the RRE.

William Auten 11:14

Yes, so uh they're the ones that that as far as fines for attorneys representing clients. I don't know.

Chantal Roberts 11:22

I've always been told it was for everybody, but there is an RRE, like the government can go against anybody, is what I was always told. So you may know more information than I, but what I was always told it was for anybody, and yeah, I don't know if the if an attorney qualifies as an RRE or not.

William Auten 11:39

That's something I'd have to look up. We should probably back up a little bit here because there's let's throw out some vocab words. If there's any uh property people here um that uh want to understand this better, your your ears might be bleeding by now. So we'll we'll back the truck up a little bit.

Chantal Roberts 11:58

We get ahead of ourselves, don't we? We're so sorry.

William Auten 12:01

We do, we did. We started at the at the end, and now we're in the middle. So um, but the the concept to to understand is this is basically no different than the subrogation situation. And uh Medicare, Medicaid, workers' compensation, and in some states, health insurance companies have a right to subrogate for damages that they pay when someone else is responsible for the accident that caused the injuries. So very simple concept there. Um, the difference is with these entities, it's um it's a government responsibility. And um the government says, well, there's too many claims, so it's not our job to go find the subrogation uh opportunities. We're gonna put a law in place that requires all these liability insurers that if you see something, you've got to tell us, which is a little bit of a different scenario because if you've got a an auto accident claim and you insure car A, who's at fault in the accident, the insurer for car B is gonna be looking uh to recover anything they paid and they're gonna go find you.

SPEAKER_01 13:13

Right.

William Auten 13:13

With Medicare, it's different. The the they want you to let them know that you owe them money. So um that's a a little bit of a different uh of a role reversal there.

Chantal Roberts 13:26

I I do I did look this up because uh I know that the government loves their acronyms, and and so I uh was looking it up, and this is one of the fun things that Bill and I were talking about is I said, Hey, I did this whole you know outline, because as everybody knows, we we we go off of outlines, and uh he's like, Yeah, I did too. And I'm like, oh, well, that means that I didn't forward you my outline. So hey. Um, but I I always got confused with all of these acronyms that the government starts throwing around, right? Because the government, like, like they like the number five, also love their acronyms. And so CMS, the centers of Medicare, Medicaid Services, is the federal agency that runs Medicare. Now, they use section 111 uh reporting to identify claims involving Medicare beneficiaries and to protect Medicare's interest when another insurer may be responsible. And that's what Bill was just talking about. So this section 111 is the federal Medicare secondary payer, which is the MSP reporting requirements. So it like branches off into that. And uh that's when we figure out what the rules are, and so the the nuance that we're getting at here is is this person meaning the injured person the actual Medicare beneficiary? And do I have enough information to verify whether they are a Medicare beneficiary? Um and so that's where we were getting off into the big five. Now, Bill, you want to tell us what a R R E is, which is another acronym. There's gonna be a test later, guys, by the way.

William Auten 15:27

It is uh it is a responsible reporting entity, and that means that under the MSP or the CMS well, Section 111 laws, that you are or your entity has to report these um payments to uh to CMS so that they they can send you a letter and let you know about all the payments that they've made. And what's interesting I'm sorry.

Chantal Roberts 15:56

I'm sorry.

William Auten 15:58

Well, what's interesting is that they call them conditional payments. So as they're paying for an injured person's medical care, and that if that injured person was hurt because of someone else's negligence, those payments are considered conditional, meaning that Medicare is paying it now because we want them to get their treatment, but we expect it back, is the is the kind of the idea. Um so it's conditional on what the existence of other insurance of other benefits that may be available. Um even if there's like other health insurance, although I don't think that happens very often if you're on Medicare and you happen to have, you know, fine coverage somewhere else that you, you know, some b policy buried in the back drawer that you never knew about, I guess. Um, but most often it's liability.

Chantal Roberts 16:57

Yeah. So let's back up again, real quick. And one of the things that I wanted to mention, because I didn't want all of the adjusters to go, holy cow, I'm not doing any of this. You probably are, you just don't realize it. And and then the the other thing is is that I don't want you as an adjuster to think that you personally are the RRE, because and you're thinking, oh my God, I'm not contacting Medicare or the CMS or this Section 11 or you know, whatever. No, no. Um when I was working at Liberty Mutual, MetLife, and then even as my third party administrator, um, what what I would do is I would input this information into the system, into our claim system, uh, and then nightly it would go over to the chosen RRE. And there's a couple of different ones throughout the insurance industry. Um, I don't know if we want to mention names or whatever, but uh it's usually not the insurer, they usually like sub that out to someone, and that other company is the RRE.

William Auten 18:21

And so it it that's partially true, but what at the outset, yes, the RRE uh uh original RRE at the base of it is the insurance carrier. This is true. This is true. They contractually then um give

Section 111 Reporting And RREs

William Auten 18:40

that responsibility to some other vendor who has the tech available to be able to populate CMS with this data. So it becomes this big tech nightmare. When it first started, this was like 2009, I think.

SPEAKER_01 18:54

Yeah.

William Auten 18:54

2009 or 10. At the company I was at, we didn't have that tech.

SPEAKER_01 19:00

Right.

William Auten 19:01

It's a very small company. So we would log in, we would set up an account with CMS and we would log in and literally report each claim that way.

Chantal Roberts 19:13

Yeah, yeah, yeah.

William Auten 19:14

And then after a few years, they stopped that portal, was no they they they eliminated it. They're like, well, not enough companies are even using it. So most of them are doing this data dump.

SPEAKER_02 19:26

Yes.

William Auten 19:27

So I spent the next five years at my company trying to get the tech in place to do that. Right.

Chantal Roberts 19:32

So and and that's why I say a lot of these companies, um it's all operating behind the scenes for the adjust from the adjuster's point of view, from the agent's point of view, from the attorney's point of view, all of that kind of stuff. But there are these these other entities that that take your data as an insurer and report it off. Now, I'm assuming that a lot, and I guess that's true. I shouldn't assume this, that a lot of our adjusters listening uh might be desk adjusters or independents who gather this big five and then turn it over to the desk adjuster who then turns it over. And I shouldn't assume that. So but but I also don't want the adjuster listening going, holy heck, I'm I'm not contacting Medicare or the CMS or data dumping or anything like that. Um yes, while it is the insurer that that is supposed to be doing this, it's your duty is really only to get this this data. And then once it gets dumped, um, you will either get a yes or no from CMS saying, yes, this person is Medicare eligible and we're we're making payments, or no, this person is not eligible and we're not making payments. And um that's when you can go, oh, thank God, they're not medical, they're not Medicare Angels. And and FYI guys, um this system that we're talking about, we keep saying Medicare, which is the the elderly one or the end of life one. Um, but the states do usually have a Medicaid one. And I don't want to get too much into that one because it's like a that's a whole nother podcast. Uh well, it's something similar.

William Auten 21:43

Yes, um you kind of need the same information.

Chantal Roberts 21:47

You do.

William Auten 21:48

Um in New York, it's it's um so first of all, the the Medicaid is always ran by the state versus Medicare, which is federal government. So With Medicaid here in New York, it's administered through each county. So if you have a claim in Monroe County, you would go to the health department in Monroe County. Wow. I happen to know there's a single attorney there whose only job is to inform you with these liens. I know her name, I know her phone number. She just says, call me when you have one.

SPEAKER_02 22:23

Wow.

William Auten 22:23

So we call her and then she sends a um the lien letter to us. Other counties are different. You have to do kind of like a FOIL request, FOIA request. Um but you're basically asking for the information about any liens that are that would be on there. So that's for Medicaid. Workers' compensation is also eligible to subrogate uh for benefits that they've paid. But that's different. That's more like a traditional subrogation situation. You're not uh we're not obligated to go find the workers' compensation carrier uh like we are with Medicare and Medicaid, but um they do have a right to subrogate uh uh for for you know uh medical bills and things that they've paid. Uh plus wages um are a component of that of that too. Health insurance companies in New York cannot subrogate. So private health insurance like Blue Cross, Blue Shield, Humana, those types of companies can't um subrogate. They can in some states across the country. I don't know which ones, but uh from what I understand, uh they are allowed to in some states. And they used to be able to here in New York, and that changed. I want to say that was around 2009 or 10, also, uh, where they they took that ability away from private health insurance companies. And um, except in New York if it's an ERISA plan, which is basically a self-funded health insurance program through a large employer. Um, those actually can subrogate. Anyway, that's that. Um, those are the the types of companies that can subrogate. Are you okay?

Chantal Roberts 24:18

Yeah, no, I'm um I'm lit I'm listening to you. I'm also um I'm sure I'm making a face on YouTube and I'm not even paying attention because I'm I'm trying to be very subtle and send um Bill notes while he's talking. Um because it yeah, and so I'm sure I'm making like this really stupid face going like completely forgetting that I'm on camera and that I'm being recorded. Uh, because that is such as the day that I am having. Um so he is absolutely right. You gotta know kind of with the Medicare uh excuse me, Medicaid, what you're looking at. I think in Arkansas, it was just like one, like the Arkansas Department of Health. That's all you needed to look at. But um there there is, like I said, just this this yeah, there's a whole thing. And her county, that's really interesting. I had not heard that before. So it behooves you to know or at least maybe have a trusted AI, uh or excuse me, IA, independent adjuster who would know this um uh about their state or what have you if you if you work in a couple of different states. Um the very uh me trying to be all stealth-like and everything, I was trying to send uh Bill the uh process, the recovery process for uh Medicare, the CMS issues, and and there's like a whole bunch, and I'm only limited to like 3,000 characters each, and so I like keep having to delete stuff because I keep loading too much in. And yeah, so what welcome to the joys of podcasting? Um, these are the things that people never talk about, and uh I just say, you know what, I don't edit these stuff out. I mean, I I don't mind that you're driving in your car laughing at me. I don't care.

William Auten 26:28

Or this is a this is a really complicated topic because the like we we couldn't the the whole process of of reporting is is a whole tech side of things that we we just as an adjuster you don't really get involved in. That's that's what the um you know the coo and the it department, their job and their compliance department, their job is to make sure that this is all done behind the scenes. And um, but but there there are some practical things for adjusters to know when it comes time to handle a claim like this and settle a claim because that starts getting impacted. When when you've got an elderly person on Medicare and they're not represented, and they have say $1,500 in out-of-pocket medical expenses, and they want to be reimbursed for that.

Chantal Roberts 27:26

And that's a lot of money, even if it's not okay. So, can I take a detour real quick? Because again, uh I I always said, even to attorneys, I'm like, I don't care. They could be three months old. I I do not care. I want all of the information because I'm going to run them through Medicare. And um a lot of people protest this. And you as adjusters need to understand that Medicare doesn't only take care of the elderly. They can take care of end-of-life people. You know, like if you had renal stage failure, uh if

Medicaid Liens And Other Subrogation Rights

Chantal Roberts 28:05

you like are have cancer, you could be on there. They could take care of some of the survivors of uh the people who were on um Medicare, or at least they could. Now that may have changed, but um, that's how you know you could sometimes get uh the 17-year-old who's perfectly healthy, but their parent wasn't or whatever. And so they were like a beneficiary in in that sense. That could have totally changed. I don't know. However, um that's why I'm saying doesn't matter. Uh you gotta run them through. And even if it's it's not just for Medicare we're looking at. Remember, we just talked about Medicaid, we should be looking at Medicaid too. Um, so that I'll turn it to the Yeah, always report it to those government entities.

William Auten 28:58

That's not not even negotiable.

Chantal Roberts 29:00

Yeah, no, it's not. It is absolutely not.

William Auten 29:03

Uh, there there is there is one exception.

Chantal Roberts 29:06

Oh, there's always an exception.

William Auten 29:08

That exception is if the settlement is less than 700 $750 or less.

Chantal Roberts 29:14

That I didn't even know.

William Auten 29:15

So Medicare uh uh that's the small settlement provision. They they don't want to be bothered with those.

Chantal Roberts 29:24

Um, so we're getting ready to talk about how to settle a claim within when you come when Medicare, when CMS, Section 11, when all of that um comes back and says, yes, there's a Medicare eligible recipient, and we have made conditional payments, which was what Bill has been talking about.

William Auten 29:44

Yeah.

Chantal Roberts 29:44

This is a huge pain in the rear. And I'm going to tell you, um, grandma, like Bill was talking about, when she's unrepresented, is not gonna understand this process because it sounds suspicious to me.

William Auten 30:01

And it does, it just sounds like a delay tactic. And it's absolutely not.

Chantal Roberts 30:07

It it completely sounds like like you are taking advantage of them. Um, I do have a flow chart uh with a with a um from the government um that I'm gonna put in the the the link in the the show notes, and um you can get it there. But it's really nice to have. I used to include that with my Medicare letter, my CMS letter that I would send to my claimant saying, this is the reason why I need it, and this is what's gonna happen if you come back, like with a quote unquote positive hit and everything, because it's gonna sound super sus, as the kids these days say, and it it it is completely not. So, Bill, I'm gonna turn it back over to you.

William Auten 30:57

Yeah. So when you have that case with the elderly person who doesn't understand what you're talking about, doesn't care about what you're talking about, they just they got hurt, they think it's somebody else's fault, and they don't even want to sue, they just want their medical bills paid. You still have to go through this process. And if it's if it's more than $750, you've got to report it to Medicare, you've got to get that conditional payments letter, and you've got to explain to them look, if we settle this with you for $1,500, there's a $1,400 lien. So you're only gonna get um $100. Yeah. So if you're out of pockets or $1,500, we're gonna add that $1,400 to it and we're gonna call it $2,900, and we're gonna make a release out to you for that much, but you're only gonna get a check for the part that we owe you. The rest has got to go to Medicaid or Medicare.

SPEAKER_01 31:54

Right.

William Auten 31:54

Medicaid or Medicaid the same applies to both.

SPEAKER_01 31:57

Right.

William Auten 31:58

And that's the proper way to handle it because otherwise you're blindsiding this claimant with um an unrealistic understanding of where the money goes.

Chantal Roberts 32:09

I think the part that really confuses them the most, and it confuses it confuses me. And and this is what sounds like we are delayed, is okay, so of course, as most liability adjusters know, we can't settle until they finish treatment. And there's a little caveat to that, but I'm not gonna get into it. So they we can't settle until they finish treatment. Okay, great. So once they finish treatment, we have to go back to Medicare. And we're just gonna call it Medicare. Just know that we're talking about Medicaid as well. But we got to go back to them and say, okay, the claimant is finished treating. What is your final kind of demand here, your conditional demand? And they're gonna go, okay, so we're gonna tattly everything up, and this is what we think that that is owed to us. Is that what you come up with? And we're gonna go, yeah, sure, that's what we come up with, you know, go ahead. And then they're going to send us, you know, they being Medicare, the government is gonna send us a demand. Great. We would you know pay that, but we we also need to get that release, right? And and like Bill said, you include those medicals in the release because you're gonna pay the whole thing. But if you're um if you're giving a release over to the claimant, they think that they're gonna get the check like right away, but there's like a long intermediary part there where the government is checking things and then they give you a final demand because they don't even give you a final demand until they it it's it's a whole thing, guys.

William Auten 33:57

It's it's it's hard, it's hard sometimes. Sometimes it goes quick. Yes, other times they say, you know, right now it's here, but there's more pending in so many words in their conditional letter. And and and you need to think about this as a lean against the settlement. It's right, it's and it's not just a demand like my hands out. It's it's whatever you pay to them, we're gonna take a piece of it.

Chantal Roberts 34:23

Yes. So um and yeah, so um it's not like you can settle yet because now you're waiting on the government. And I will say this, they have gotten a lot faster. I mean, back in the day, like 2009, 2010, 2015, I mean, it took a month, two months, something like that. I mean, it took a long time. Meanwhile, grandma's over here going, look, I just want my $1,500. I can't make you know, rent, or I can't buy my medicine, or I can't do this or that, or whatever. Because meanwhile. Yeah, because meanwhile, all of this meds they still keep coming up to um Medicare, and Medicare is then running all of the new meds against the date of loss, and you know, the CPT codes and the ICD 10 codes and all of that, making sure that it the new bills aren't related to the old injury and need to be added to the demand. Do you see how confusing this is? It sounds suspicious, and now you know you're trying to explain this to grandma who doesn't trust you because you're just some voice from you know Wisconsin or whatever, you know, I don't know. Um, so yeah. So finally, all said and done, you get the final demand letter. Okay, woo! So you pay it and um you can settle with your claimant, being that it's $2,900, we're gonna give you $1,500 because the rest had to go to you know, Medicare or whatever, and then boom, you're done finally, yay. Um, but you have to sign that release first before I and it yeah, it's a whole thing. And it is a whole thing. And then let's say that Medicare, Medicaid, they make mistakes,

Settlements With Conditional Payment Demands

Chantal Roberts 36:20

they accidentally add some things on that you don't think is covered. Here's the fun thing about this adjusters it is it behooves you as the insurer, and I know that you're not the insurer, but it behooves the insurer to pay it because again, I mentioned there's a thousand dollar a day fine if you don't pay it per claim. So, what I was always told uh was you pay the whole thing, and then then you file the appeal or the contestment of that particular part because you do not want to be fined a thousand dollars a day. And allegedly, and I've never known anyone. If you have, please let me know. Please write it in the show notes, send Bill and me an email, whatever. I have never known anyone who has appealed anything, but allegedly the government gives you your money back.

William Auten 37:22

I I've not um I'm not familiar with any companies that have uh have been fined.

Chantal Roberts 37:28

Uh I'm not saying that they haven't been, but what I heard was what I heard was uh we all had that grace period up until I think 2024 was a long time. It was like we had a really long grace period because the government was like easing us into this, and I think the grace period ended in 2025, and so they started now, but I always operated as if the fines were active right then and there because the the government could, like I said, um they told me that they could go after anybody, the attorneys, us, the third party administrator, doesn't matter. Uh I know it's supposed to be the RRE, but it could be anybody. And the RRE is usually the insurer. Okay, so anyway, um that is the other thing that I wanted to drill into people is um make sure that the payment gets done and then you can contest later. But if you know of someone who contested it, let me know because I I hear you're supposed to get your money back. That's true.

William Auten 38:39

So there's um there's another way to handle um handle this, and it's not uh something I would recommend, but in strange cases where it makes sense to settle and and you and you don't know whether they have Medicare or Medicaid, if you explain to them that look, if you have either of these uh and we pay you directly, you are going to owe it because we're gonna put in our release that you are responsible, then we're gonna transfer that responsibility to you and you're gonna sign this release that says you agree to that. So if we settle with you for ten thousand dollars and a year from now, after you signed a release, you get a call from Medicare or we get a call from Medicare saying that there's two thousand dollars owed to them, um, we're going to send them your contact information and and you and a copy of the release that you signed, and then you will have to pay that out of the funds that you um but it the the I've never really seen anything uh happen like most of the carriers I work with uh use releases with that language in it.

Chantal Roberts 39:53

In it anyway. I have told attorneys who refuse to give me that information. I'm like, okay, well, I'm gonna need you to sign a hold harmless and indemnification.

William Auten 40:04

Right. You know, because you're gonna that's the that's about the only example where if you get a belligerent claimant or attorney that won't share the information.

Chantal Roberts 40:12

Yes. Um and and I hate to say this a lot of times, but sometimes you can get the information from uh this the the medical bills, you know, because they they'll have the um social security number especial.

William Auten 40:33

Medical records sometimes will have it. If if they refuse to give it to us, we'll we'll review everything that we have because sometimes it it is buried in there. And remember that's PII people. That means that is private information. So don't email it to each other and uh don't email social security numbers to each other. I get that from attorneys all the time.

Chantal Roberts 40:52

Yeah, yeah.

William Auten 40:53

I'll leave a message hey, I just call in to see if I can get the insurance, uh the claimant's social security number. Ten minutes later, I'll get an email. Oh, here's the social security number you asked for. It's like, are you kidding me?

Chantal Roberts 41:05

Can't do that. Um, yeah, so we we've talked about the ethicalness of that, and that is that's a huge part. Uh the PPI, personal protected information. Um is of course part of that big five, which you know is name, date of birth, gender, so security number, uh, address, all of that kind of thing. Uh, it are the things that needed to be identifiable to you. And and again, explaining this whole process to someone who is automatically uh opposed to you because property adjusters, y'all know that the insured already thinks that you're not gonna offer enough money for the roof or the car or whatever, but the liability adjusters get a whole different set of it, you know, because um, you know, they're it's it's kind of the same thing. They're mothers, next door neighbors, aunts, best friends, third grade teachers, ex-husband had the exact same, you know, injury as as you, and they got $50 billion, or right, you know, whatever. It's gonna be that same set, but it is automatically 10 times as worse as I felt as a liability adjuster compared to a property adjuster. And that is because a lot of it is subjective, such as the pain and suffering uh that we that we do. And so now we're coming in with something else that that sounds even more suspicious, like this government entity, and they're going to first send you a conditional demand, and then they're going to think about it, and then they'll send you a final demand. And meanwhile, I can't settle until I get all of this, and then I got to pay them, and then I'm gonna pay you the difference. You know, it just it sounds super suspicious. So if you have the letters and uh even pointing, I think, claimants to the websites, the governmental websites, so that they can read it and understand what you are up against is is very helpful.

William Auten 43:31

My my advice is to learn all you can about it so that you can verbalize what's going on in layman's terms to the average Joe, because that's who you have to communicate this to. And you can't do it using acronyms and word salads and alphabet soup. You've got to be able to describe the process from start to finish, and you have to remember. That in their mind, they're going to be thinking this is just a delay tactic, they just don't want to pay anything, they're trying to pay as little as possible and they're trying to stretch this out as long as they can. Not the case. We would rather get all of the claim information on day one so we can close it on day two. This is a busy job, you know.

Chantal Roberts 44:19

Exactly. And you know, you mentioned that, and uh to all the CEOs who are listening, um, not that there are any, but that's okay. Uh, you know, there was this huge push, what, about 10 years ago, to do that first call settlement or whatever. And uh I remember when that was coming out, and I'm like, you know, that doesn't work anymore with Medicare and Medicaid because we still gotta go run them through. And so there isn't this no, and I don't know if that's still going on. I guess if it's under that $750, but I don't I have actually never had any success with this first call settlement.

William Auten 45:01

Um so here's another thing that happens with the $750 uh threshold. When you explain that to someone,

Paying First, Disputes, And Hold Harmless

William Auten 45:10

they instantly think, oh, he's just trying to get me to settle for $750 when my claim is clearly worth more than that. Right. It's it just puts us in such a box, and it's no wonder that there's these stupid books that come out, you know, complaining about denies and you know, yes, delays saying the name of the book, but uh yes, exactly. Um it it it puts us in a real spot, and it's not the insurance companies that have done it as much as it's regulatory that has really, you know, they it happens with a lot of government programs, they think they're trying to help and they're really just making things worse.

Chantal Roberts 45:53

Yes. Um, so I'm I'm going through my notes um real quick just to see. Um reporting requirements, just to make sure. I know we've been jump jumping around a little bit, but I just want to make sure that we've kind of touched about um all of the things. Um reporting requirements, the liability insurance, no fault insurance, workers' compensation. You had mentioned all of those. Bill, Bill is much more uh uh in touch with that since he does a lot of the liabilities. And it's been years since I've been in liability. I love liability, it's fun. Um, I I do think it's a lot of fun. I will put I will I will give you the the flow chart, which I think is absolutely fantastic to offer to claim it's and it's it's the government's, it's not mine, it's it's not anything. So I mean, there's no problem with giving that information um away. And um yeah, so story time real quick.

William Auten 46:55

And yes, uh before we wrap up, we had um claim about a year or two ago. The attorney, the attorney said he submitted the um some medical bills for a person who was on Medicare. And he said, can you just pay these out of Medpay? And there's I've heard some carriers argue that MedPay doesn't count. I don't think that's the case. I think MedPay uh it goes into the same bucket as everything else that if you pay on med pay without paying Medicay, Medicare first, you're in hot water. Nonetheless, um he said, just you know, can you just pay these? And I said, No, we can't. We have we first we have to get the the big five as you call it. And uh and he said, why? And I said, we have to report it to Medicare, to CMS. He goes, No, no, no, I don't want that. I said, I don't care.

Chantal Roberts 47:49

Do not care. Thousand dollars a day fine. Do not care.

William Auten 47:52

It's not an option for you, Bob. Uh so uh I I had to and I think what his mind was his mind was more along the lines of the way um no fault and loss transfer work in auto claims, because I think he primarily did auto. I I don't know. I don't know where the confusion came and why he didn't know this, but anyway, um, so you you have to watch for that. Not like attorneys are smart folks, but sometimes they wander into this realm of of claims and and cases that they're not really familiar with, and you have to kind of just educate them a little bit.

Chantal Roberts 48:32

Yeah, and I would I would agree with you, Bill, that the the the government says no fault. So to me, that is pip, that is med pay, that is, you know, slipping you the the med pay that we have in our homes. I mean, this we're we're I think we're kind of giving the impression that this is only like auto or commercial or whatever, but this can happen in your homeowners claims as well, you know.

William Auten 49:01

Commercial general liability, your home, even if you're a renter.

Chantal Roberts 49:04

Yes. Um worker's comp.

William Auten 49:06

If you're asking me how many dog bite claims we have with renters, you know.

Chantal Roberts 49:10

Yeah. So yeah, yeah. So uh you have a workers' comp claim. It that is specifically mentioned. So uh these are things to to understand. So uh you know, identify our lien holders early, get that big five information, the key, the the personal identification information uh early uh so that we can turn that over to if we're the independence, either the insurance company or put it into our system and then let it go. Because again, I don't want the adjusters to worry too much about it because they don't they're not the ones who usually call Medicare or Medicaid or whatever. It's someone that the insurance company's contracted with. And then once you get the letter back or you get the answer back, yay or nay, you know, that's when you need to know which way you need to go. And uh of course, you've already explained all of this to the claimant on your first call why you're asking this information. You've sent out a letter, and so you can even, when you get the information back, call the claimant up and go, hey, I I've gotten a positive hit on you. You know, you're you Medicaid and Medicare, whatever is is paying this. So this is going to impact how we settle. You might want to explain it right then and there, because again, it sounds sus. It sounds really suspicious.

William Auten 50:42

Um and and and there's no quarrel with reimbursing Medicare for the city. No, no, no, no. It's not that's not what is annoying about this whole process. The the part that's annoying is that it forces you to have conversations with claimants that make it sound like you're trying to delay because it they've imposed this delay thing on us now, and that we we have to comply. That's the annoying part. The reality is I want to know how much Medicare has paid in medical because if we get a demand from an attorney for a million dollars and we get a Medicare lien for 2,500 bucks, kind of changes the outlook on the claim, doesn't it?

Chantal Roberts 51:27

Yeah. So absolutely, yeah. Um, so again, you know, of course, you know you're gonna document all your conversations, you're gonna do that anyway. Uh, I would just make sure that that uh your notes are very clear and um I would resist letting people know that um they can settle themselves because again, it's the insurer. Although I've always been told the government can go after whoever they want, um, it's the insurer who is ultimately responsible. And we're talking about $1,000 a day fine.

William Auten 52:03

Do you mean uh do you mean a uh property owner settling with a claimant?

Chantal Roberts 52:07

No, no, no, no, no. Well, they're not supposed to do that anyway. I'm talking about like if the if the attorney and and I had many an attorney say to me, I will settle with Medicare myself.

William Auten 52:17

Oh, oh, I see. And you well, that's where the release comes in.

Chantal Roberts 52:21

Yes, and and usually what um that what the attorney is wanting to do, and I don't think I'm putting out any kind of things that that the attorneys don't want us to know and that no adjuster

Real Claim Example And Closing Requests

Chantal Roberts 52:35

doesn't already know, is that they want to try to negotiate that lien down, just like the the attorneys want to settle with the doctors themselves. Uh, they try to negotiate the doctor's bills down, which puts more money in their client and their pockets, which is, I mean, fine. I don't I don't care as long as my claim is is settled, I've paid the fair amount, my my client, which is the insured, is protected, you know, uh and and everything. That's what I care about. So um, yeah, uh that's when, as you and I talked about, I I I would not let the attorney do that, or the claimant if that's what the claimant wants to do the with Medicare CMS themselves. I would want to hold harmless.

William Auten 53:23

It's a risk, it's a risk.

Chantal Roberts 53:25

Yeah, I would want to hold harmless and indemnify.

William Auten 53:27

Yeah, and unless that's a very sophisticated claimant that maybe is an attorney, or I don't even know if I would trust them then.

Chantal Roberts 53:35

I I would run that up the flagpole anyway. Um, yeah.

William Auten 53:41

Just new our next topic.

Chantal Roberts 53:44

Oh my gosh, our next topic in in two weeks. I'm sorry, I keep going on. Um, is how to do a good recorded statement. I thought that would be we we mentioned that a couple of of episodes ago, like uh we did we did one on that um a while back and it was very popular.

William Auten 54:02

So I I think uh a reboot uh would be a good idea.

Chantal Roberts 54:05

Oh, I didn't even I see this is this is me. I I don't remember what happened yesterday, so I don't even remember doing that.

William Auten 54:13

So whoops, you were awesome in that one, by the way.

Chantal Roberts 54:15

Was I really? I think I find that really hard to lame. But okay. Um, yeah, so uh anything else? Um yeah. Like, subscribe, listen, share, let us know, questions, whatever.

William Auten 54:35

Follow us on LinkedIn. Yes, send us liability claims here at Ot and Claims Management.

Chantal Roberts 54:41

Uh send me expert witness claims at CMRconsulting.net. Or yeah, hire me as a teacher or whatever. I'm so entertaining. All right, we'll talk to you later, Bill.

William Auten 54:56

All right, take care. Bye-bye. Thanks for joining us on the Art of Adjusting Podcast, where we talk about life as an insurance adjuster. Hit that subscribe button real quick and tell all of your adjuster friends to check this out as well. For independent adjusting services, go to www.autin.claims. And for anyone interested in working as an independent liability adjuster, go to the contact us tab to join our roster.

Chantal Roberts 55:21

So this wraps up another Art of Adjusting podcast. If you enjoyed this podcast or this episode, please give us five stars and a review. It does help the algorithm pick us up. In the meantime, you can contact me at theartofadjusting.com for consulting and training purposes.