42 CFR 411.37 - Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.

§ 411.37 Amount of
Medicare
recovery when a primary payment is made as a result of a judgment or settlement.

(a)Recovery against the party that received payment -

(1)General rule.

Medicare
reduces its recovery to take account of the cost of procuring the judgment or settlement, as provided in this section, if -

(i) Procurement costs are incurred because the claim is disputed; and

(ii) Those costs are borne by the party against which CMS seeks to recover.

(2)Special rule. If CMS must file suit because the party that received payment opposes CMS's recovery, the recovery amount is as set forth in paragraph (e) of this section.

(b)Recovery against the primary payer. If CMS seeks recovery from the primary payer, in accordance with § 411.24(i), the recovery amount will be no greater than the amount determined under paragraph (c) or (d) or (e) of this section.

(c)

Medicare
payments are less than the judgment or settlement amount. If
Medicare
payments are less than the judgment or settlement amount, the recovery is computed as follows:

(1) Determine the ratio of the procurement costs to the total judgment or settlement payment.

(2) Apply the ratio to the

Medicare
payment. The product is the
Medicare
share of procurement costs.

(3) Subtract the

Medicare
share of procurement costs from the
Medicare
payments. The remainder is the
Medicare
recovery amount.

(d)

Medicare
payments equal or exceed the judgment or settlement amount. If
Medicare
payments equal or exceed the judgment or settlement amount, the recovery amount is the total judgment or settlement payment minus the total procurement costs.

(e)CMS incurs procurement costs because of opposition to its recovery. If CMS must bring suit against the party that received payment because that party opposes CMS's recovery, the recovery amount is the lower of the following:

(1)

Medicare
payment.

(2) The total judgment or settlement amount, minus the party's total procurement cost.

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United States Code

Title 42 published on 16-Nov-2018 03:48

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 411 after this date.

  • 2018-11-23; vol. 83 # 226 - Friday, November 23, 2018
    1. 83 FR 59836 -  
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Final rules and interim final rule.
      42 CFR Part 405