Avoid Unexpected, Duplicate Medicare Files Created by Section 111 Insurer Reporting in Medical Malpractice Cases

April 5th, 2021

Avoid Unexpected, Duplicate Medicare Files Created by Section 111 Insurer Reporting in Medical Malpractice Cases

By: Yeganeh Gibson, Esq., CMSP  | Lead Lien Attorney, Precision Resolution, LLC  |  Click to Email Yeganeh

At Precision Resolution, we often see medical malpractice cases come our way where Plaintiff’s counsel has already reported a settlement to Medicare and received a closure letter, only to be surprised to learn that a new Medicare file has been opened upon the insurer’s mandatory Section 111 reporting, with a significant increase in the Medicare payments.

In one such case, Plaintiff, who had been suffering from hypertension and kidney disease for years, had an MRI of the kidneys in 2010. While a small mass was identified in his right kidney, it was dismissed as benign. Plaintiff continued to treat his kidney disease. Several years later, in 2015, it was discovered that the mass had actually been cancerous. Plaintiff asserted a medical malpractice action against the defendant-doctor for failure to timely diagnose and treat the kidney cancer in 2010.

Plaintiff’s attorney proceeded to open a file with Medicare using the date of the cancer diagnosis–2015. No conditional payments were identified by Medicare and the file was closed. However, a few months later, Medicare issued a new letter with a new date of injury: plaintiff’s first encounter with the defendant-doctor in 2010. The insurance carrier had reported this case under Section 111. Medicare was seeking over $145,000 in conditional payments for the kidney under this new file, including treatment for end-stage renal disease and kidney transplant surgery.

After a thorough analysis of the medical records, expert reports, and review of the individual conditional payments, Precision’s attorneys developed substantial arguments that demonstrated the conditional payments were unrelated. Medicare agreed and reduced the file to zero.

Best Practices Tip: This scenario may be prevented by providing Medicare with the proper date of incident. At Precision Resolution, we ensure that your case has the proper Medicare date of incident. We monitor and remove all unrelated charges, so that the risk-of-loss is not borne by the Plaintiff and counsel after settlement – and we take care of any duplicate files opened under Section 111 reporting.


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