Workers’ Compensation Pays Primary to Medicare

Workers’ Compensation Pays Primary to Medicare When a Medicare Beneficiary Has a Work-Related Medical Claim

Medicare serves as the primary federal health insurance for individuals aged 65 and older in the United States. Individuals under 65 who receive Social Security or Railroad Retirement Board disability benefits become eligible for Medicare after 24 consecutive months of receiving disability benefits. Additionally, individuals of any age suffering from end-stage renal disease (ESRD) may qualify for Medicare.

When it comes to beneficiary claims for Medicare involving non-Medicare payers like Workers’ Compensation, the responsibility for primary claim payment lies with Workers’ Compensation. This coverage is crucial for workers dealing with injuries or illnesses resulting from workplace incidents. In 2016, Workers’ Compensation provided $61.9 billion in medical and monetary benefits, covering over 138 million jobs in the United States. It’s important to note that Workers’ Compensation coverage, benefits, and reporting requirements vary across states.

Despite the significance of Workers’ Compensation, there is a lack of a centralized database for this information. Medicare claims data can offer insights into occupational health research and surveillance to determine the work-related nature of injuries and illnesses, but it comes with its challenges. According to the Medicare Coordination of Benefits Rules, Workers’ Compensation takes precedence over Medicare and Medicaid for workplace injuries or illnesses.

The study aims to analyze over two million Medicare claims where Workers’ Compensation had primary responsibility. This includes examining associated Medicare beneficiaries, their healthcare utilization, and the financial costs involved.

Challenges arise from incomplete information about a beneficiary’s employment status during the claim, leading to confusion regarding whether the claim is for an employed Medicare beneficiary, ongoing medical treatment for a previous workplace injury or illness (potentially before Medicare enrollment), or if workplace exposure contributed to a pre-existing condition worsening.

A subset of claims with detailed E-codes provides insights into the causes of workplace injuries or illnesses. For instance, costly claims often result from incidents like motor vehicle traffic accidents, explosive accidents, or fire injuries.

Disability-related details for Medicare beneficiaries are unavailable in event-related claims. However, understanding disability origins is crucial, as 44.2% of beneficiaries in this study became entitled to Medicare due to disability. This emphasizes the need for surveillance and tailored workplace interventions for those with disabilities.

Inquiries about work-relatedness during medical checkups can help coordinate insurance benefits, assist with occupational health surveillance, and contribute to effective recovery or disability management for those returning to work.

The study excludes certain workplace claims, such as medical claims with unfiled Workers’ Compensation claims, claims for individuals not enrolled in Medicare, or claims not covered by Workers’ Compensation. It focuses solely on Medicare beneficiary claims, representing a fraction of all Workers’ Compensation claims over 17 years of Medicare data, which includes $1.106 billion in paid Workers’ Compensation claims.

Workers’ Compensation paid $31.2 billion for medical and hospitalization expenses in 2017, with an average claim totaling $22,219. These costs reflect the combined short and long-term impact of work-related injuries, potential chronic health conditions, and the involvement of various responsible payers once an employee enrolls in Medicare.

Multiple stakeholders could further study the long-term financial benefits of occupational health prevention and interventions to prevent or reduce work-related injuries or illnesses.

The study’s limitations include inconsistent data reporting of workplace events or beneficiary employment information. Additionally, since most Medicare beneficiaries are aged 65 and above, the findings may not fully represent all Workers’ Compensation claims.

The lack of data on reimbursements made or payer payment details, especially for home health agencies and hospice claims, poses challenges. The study also acknowledges the limitations of collecting Medicare claims data for billing purposes rather than public health surveillance.

This study aims to enhance the collection and surveillance of workplace medical claims among Medicare beneficiaries for occupational health research and intervention strategies, addressing a gap in previous epidemiological studies. The use of universal standards and non-billable ICD external cause of injury codes in Workers’ Compensation primary payer claims could significantly inform workplace injury and illness prevention procedures.

The analysis focuses on Workers’ Compensation claims within the Medicare population, emphasizing the importance of understanding claims from individuals older than 65 and providing national estimates for Workers’ Compensation beneficiary payments and claims enrolled in both Medicare and Workers’ Compensation.

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