42 U.S.C. § 1395gg — Overpayment on behalf of individuals and settlement of claims for benefits on behalf of deceased individuals

(a) Payments to providers or other persons treated as payments to individuals: A payment under this subchapter to a provider or another person for an individual’s items or services is treated as a payment to that individual. (b) Incorrect payments on behalf of individuals; payment adjustment: If more than the correct amount was paid for an individual’s items or services and the Secretary decides that the excess cannot be recovered from the provider or other person within the time set by the Secretary, or that the provider or other person was without fault, or if a payment was made under section 1395f(e), the Secretary must make a proper adjustment under regulations issued after consulting the Railroad Retirement Board. The adjustment is made by reducing later payments owed to the individual under Social Security subchapter II or the Railroad Retirement Act of 1974. If the individual dies before the adjustment is complete, it is made by reducing later payments owed to another person under those laws based on the deceased person’s wages, self-employment income, or compensation. As soon as practicable, the Secretary must certify the overpaid amount for the adjustment; the certification goes to the Railroad Retirement Board when that Board will reduce the later Railroad Retirement Act payments. Unless there is contrary evidence, a provider or other person is treated as without fault if the Secretary decided the payment was excessive after the fifth year following the year in which notice of payment was sent to the individual. The Secretary may shorten that five-year period, but not below one year, if consistent with this subchapter’s purposes. (c) Exception to the subsection (b) adjustment: There is no adjustment and no recovery when the individual was without fault, or when the adjustment or recovery would reduce payments owed to another person who was without fault under (b)(4), if doing so would defeat the purposes of subchapter II or XVIII or would be against equity and good conscience. An adjustment or recovery against a person without fault is against equity and good conscience for an incorrect payment for expenses that could not be paid under this subchapter because of section 1395y(a)(1) or (9), when the Secretary decided it was incorrect after the fifth year following the year notice was sent. The Secretary may shorten that period, but not below one year, if consistent with this subchapter’s purposes. (d) Liability of certifying or disbursing officer for failure to recoup: A certifying or disbursing officer is not liable for an amount the officer certified or paid to a provider or other person if recovery or adjustment was waived under (c), or if the adjustment under (b) was not completed before every person whose benefits could be reduced died. (e) Settlement of claims for benefits for deceased individuals: If a person received services payable under this subchapter, dies, and the services were paid for outside this subchapter before the Medicare payment due for them was completed, the amount due, including unnegotiated checks, is paid in this order. (1) It goes to the person or persons the Secretary’s regulations identify as having paid for the services, or, if the deceased person paid before death, to the estate’s legal representative, if any. (2) If none qualifies under (1), it goes to a surviving spouse identified by the Secretary who lived in the same household at death or was entitled for the death month to a monthly benefit based on the same wages and self-employment income. (3) If none qualifies under (1) or (2), or that person dies before payment is complete, it goes to the child or children who were entitled for that month to benefits based on the same wages and self-employment income, in equal shares. (4) If none qualifies under (1)–(3), or all such people die before payment is complete, it goes to the parent or parents who were entitled for that month to benefits based on the same wages and self-employment income, in equal shares. (5) If none qualifies under (1)–(4), or all die before payment is complete, it goes to the surviving spouse identified by the Secretary. (6) If none qualifies under (1)–(5), or all die before payment is complete, it goes to the child or children identified by the Secretary, in equal shares. (7) If none qualifies under (1)–(6), or all die before payment is complete, it goes to the parent or parents, in equal shares. (8) If none qualifies under (1)–(7), or all die before payment is complete, it goes to the deceased person’s estate’s legal representatives, if any. (f) Settlement of section 1395k benefits for deceased individuals: If a person who received medical or other health services payable under section 1395k(a)(1) dies, made no assignment of the payment right before death, and the services have not been paid for, then (1) if the service providers agree to the assignment terms in section 1395u(b)(3)(B)(ii), payment goes to them; (2) if they do not agree, payment is made from an itemized bill to the person who has accepted the legal duty to pay and requests payment with required proof of that duty. The amount and conditions are the same as if the recipient had lived. (g) Refund of premiums for deceased individuals: If a person enrolled under section 1395i–2(c) or 1395p dies and premiums for that enrollment were received for a month after the death month, the Secretary must refund them to the person or persons identified by regulation as having paid them, or, if the deceased paid before death, to the estate’s legal representative, if any. If no one qualifies under that sentence, the refund goes to people in the priority order in (e)(2)–(7). (h) Appeals by providers or suppliers: Despite (f) or any other law, the Secretary must let a provider or supplier appeal a Secretary decision under this subchapter about services provided to a person who later died when no other party is available to appeal.