Glossary

Lien Resolution Glossary

 

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

 

Appeal (Medicare)

When a Final Demand, Final Determination, or Final Compromise has been reached, but there are errors in the calculation of the lien on the part of the lien holder, an appeal is submitted, identifying the error and requesting a correction. In most cases, an appeal request is submitted only after the Final Determination has been made if there are unrelated claims or an incorrect calculation of the final lien. Appeal decision timeframes can vary by lien holder; Medicare requests a minimum of 60 days for a response to any appeal requests.

 

 

Compromise (Medicare/Medicaid)

When a lien has been established by Medicare or Medicaid, a compromise can be proposed in an attempt to reduce the lien beyond the standard reduction for procurement costs (Medicare). A compromise may be granted if the case meets the consideration requirements by CMS.

 

 

ERISA

Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001-14679(200)) establishes and governs employee health plans and defines their right to recover in third party situations.

 

 

Insured

An employee benefit plan where the employer has purchased a plan from an Insurance company to provide benefits for their employees. A Form 5500 can identify if a plan is insured.

 

 

Medicaid

Need-based health insurance plans administered by state and funded federally. Eligibility and income requirements vary by state, and sometimes by county. Generally, Medicaid recipients are all ages, with some programs developed specifically for children of low income families. Medicaid programs cover both hospital and outpatient care, and may offer prescription drug discounts or benefits. Medicaid Institutional Care Program (“ICP”) provides benefits for those in nursing homes.

 

 

Medicare

A health benefit plan for the aged and disabled administered by the Centers of Medicare and Medicaid Services (CMS). To qualify for Medicare, a beneficiary needs to be 65 and older, disabled (if under age 65), or suffering from End Stage Renal Disease (permanent kidney failure). Medicare consists of Part A – Inpatient Hospital / Skilled Nursing Facility benefits, Part B – Outpatient care, doctor visits, and supplies and Part D Prescription Drug benefit. Part C plans are Medicare Advantage HMO policies that are fee for service plans.

 

 

Resolution

The process of negotiating a lien until final resolution is reached. This may include the pursuit of compromises, appeals or waivers until the lien holder produces their final offer for recovery.

 

 

Self-funded

An employee benefit plan where the employer is providing health care benefits out of pocket. Larger companies are often self-funded; some may hire an insurance company in an administrative only capacity – to handle claim processing and related functions. A Form 5500 can identify if a plan is self-funded.

 

 

Tricare

Military Heath System administers military healthcare coverage for uniformed soldiers and their dependent families. Tricare beneficiaries include active duty, National Guard, Reserve, and retirees (Tricare for Life for those with Medicare benefits). Tricare allows beneficiaries to receive care and services through civilian providers and facilities.

 

 

VA

Department of Veteran’s Affairs administers benefits to those who were enlisted in any U.S. Military branch and have served during wartime. VA health benefits extend coverage to beneficiaries who receive care in a VA hospital or facility, or for VA authorized services in a civilian facility. VA benefits cannot be used in conjunction with Medicare benefits; they can only be used one at a time, though a beneficiary may have both. For more information, go to www.va.gov.

 

 

Verification

The process of determining if an insurer has a lien (affirmative obligation to the lien holder). If there is a lien, the case is negotiated to completion (lien resolution).

 

 

Waiver

In very special cases where a Medicare lien cannot be repaid by a beneficiary, a waiver request can be submitted to Medicare. This request is made by using form SSA-632-BK, and describing the financial situation along with the reason for the inability to reimburse Medicare after an overpayment.

 

 

TESTIMONIALS

“Synergy is our guiding light for deferring our contingent legal fees and planning for retirement. The lawyers at Panter Panter & Sampedro, myself included, have been working with them for over ten years using different methods to defer comp and plan for retirement.”

Brett Panter
Panter, Panter & Sampedro

"I don't think I've directly said "thank you" for helping us with Bridgett’s case. We sent the reduced payment to Medicaid and called Bridgett's mom to tell her approximately how much money was going to be left for Bridgett and she broke down over the telephone. Given only $25k of insurance and a $850k medical bill from the hospital she didn't think Bridgett would ever see a penny."

Tom L. Copeland
Jeffrey Meldon & Associates, P.A.

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