Posted On: October 6, 2007, 12:07 pm CDT

Posted By: MG

Diana: I am not familiar with all of Medicare's regulations. I have seen where Medicare has paid the medical bills of pedestrians in accidents involving autos. I am not sure what changes the situation in your case. In the few situations where Medicare was involved, once they received the EOB advising that PIP was not applicable, they simply paid the bills and, if needed, filed a lien on any settlement coming from the at fault party. This is done in workers comp cases as well.

http://www.cms.hhs.gov/MSPRecovClaimPro/

According to the above site, Medicare has the option to make the payments and seek recovery from who they claim is the primary carrier and have it applied to any settlement. Since you are saying that the 3rd party is not offering enough to even pay the outstanding bills, then Medicare should be put on notice that the "primary" insurer does not intend to pay or at least not promptly, as worded in their rules, and that Medicare should then make the conditional payments for the treatment you require and file for recovery from the at fault party. In addition, I would contact the Department of Insurance for the State of Ohio and file a formal complaint, you can generally do this online, and advise that the insurer is acting in bad faith of resolving the direct losses caused by their insured. If their state works as Florida does, then the company is required to respond to the state with the specific reasons for their actions and their pursuit towards a settlement to protect their insured. You may also try a local TV investigation unit to get involved. This will just get some light on the situation more than anything and may not necessarily change Medicare's stance.

Like you said, the insurance laws are very screwed up in that each state is different and Medicare is federal. The reinstatement of PIP in Florida will not solve anything for many people. I have not read all of the details, but the only proposal that I heard being brought up was the same PIP as before only possibly attaching a Medicare fee schedule. Although a step in the right direction, this is far too little this late in the game. I have seen the fraud that occurs on a daily basis at every level. In the end the average consumer is the one hurt. The doctors treat for the limits of your benefits rather than to heal your pain. When the money is gone you are stuck in a similar situation that doctors who could actually help don't want to treat you and at that point the settlement will take in to account the first treatment as worthless and wont be enough to cover the treatment you need. So the doctor got the paycheck, if an attorney was involved he gets his 40% and the consumer gets an unresolved injury. And the legislators feel this is a good system to continue using rather than try to fix it.

You spoke of medical payments (MEDPAY). It depends on the individual insurance company on what situations it will apply. Some companies apply the same conditions as PIP and others have far more restrictions on it.

Also I know you mentioned other treatment not related to the loss. The bills should be submitted on CMS-1500 forms or something similar. They have a specific area designated to inform Medicare or the insurer whether this was the result of an auto accident. I am not sure why Medicare would be advising that it does not matter. Again, I have dealt with Medicare very little myself.

I hope that some of this helps in your situation. The vast majority of people do not know how insurance works (this includes all insurance). people do not know that they should read their policy and that the state may impose additional rules on top of that. I don't think this will change any time soon regardless of what changes are made to the laws.