Question

A 66-year-old patient was treated in the urgent care center for a fractured wrist. The patient said, "I was moving a cabinet for my boss when it fell over and hit my wrist." The office billed Medicare and received reimbursement of $550. Which of the following would apply in this situation?

A. The office must give the $550 check to the patient, who should contact workers' compensation.
B. The office should bill the employer's workers' compensation for only the Medicare coinsurance and deductible due after receiving payment from Medicare.
C. The office should have billed the employer's workers' compensation payer for the visit.
D. The office was appropriately reimbursed $550 by Medicare for the urgent care visit.
E. The office is guilty of both fraud and abuse according to HIPAA because of accepting the $550 payment.

Answer 1

The office should have billed the employer's workers' compensation as it should have been the primary payer for an on-the-job injury. Receiving a Medicare payment was inappropriate and needs to be refunded so the workers' compensation insurance can be billed correctly. The correct option is C.

Step-by-step explanation:

If a 66-year-old patient was injured while performing a task for their employer and subsequently treated for a fractured wrist, the correct action would not be for Medicare to pay for the urgent care visit. This situation would typically fall under a worker's compensation case, because the injury occurred in the scope of the individual's employment.

Since workers' compensation is responsible for covering injuries that occur on the job, the urgent care office initially should have billed the employer's workers' compensation insurance.

The reimbursement by Medicare in this case was not appropriate because workers' compensation should have been the primary payer. If the office received payment from Medicare, they would need to refund Medicare and bill the workers' compensation accordingly. The correct option is C.