A question on CMS Queries

Medicare Set-Aside Blog on February 10, 2011 | Posted by

From the NAMSAP list Serve:


“My clients are having issues with some queries coming back with a “yes” response to someone being a Medicare recipient, when in fact they are not a Medicare recipient at the present time.  Say for instance the claimant was on SSDI and Medicare ten years ago, but returned to work and  therefore stopped receiving both benefits.  The query is saying that claimant IS a Medicare beneficiary now, even though they are not.  I have seen some claimants go to their local SSA office and get someone to put on SSA letterhead that the person is not currently a SSDI or Medicare recipient which I think would suffice to use in determining whether or not to obtain a formal MSA.  But my concern is with the reporting requirements.  If Medicare thinks the claimant is on Medicare (through the query) then are they going to try to impose penalties against the insurance company for failing to report the settlement?”


Answer from John Campbell:


“From day one, CMS has acknowledged that their query system can produce both false negatives and false positives.  The ONLY way to get a reliable answer on current Medicare eligibility is to inquire through the SSA.  Since the SSA is still officially in charge of Medicare enrollment (a historical vestige from the period of 1965-1977 when the SSA was completely in charge of Medicare), the SSA benefit statement should be accepted over a CMS query response as definitive proof of Medicare eligibility one way or the other.”


MEDVAL Comment: John Campbell is one of the few MSP experts out there that gets this business. As he demonstrates, to be an effective MSP advocate you have to have experience with the past to understand the present and maybe even predict the future.


Thanks to the Law Offices of John Campbell for his insight into SSA/Medicare program history. He can be reached at 4610 S. Ulster St., Ste. 150 Denver, CO 80237 (303) 290-7497