On November 17, 2016, the Commercial Repayment Center (CRC) provided a teleconference regarding coordination and recovery of payments made by Medicare related to liability, no-fault or workers’ compensation claims.
The Benefit Coordination and Recovery Center (BCRC) is responsible for collecting payments made by Medicare from a claimant. The CRC is responsible for recovery of conditional payments against an “applicable plan.” An applicable plan is an insurance carrier or workers’ compensation entity that has been identified as responsible for reimbursement for payments made by Medicare. Additionally, an applicable plan may have certain reporting requirements under Section 111 reporting. This may include requirements of “Ongoing Responsibility for Medical” (ORM reporting) or reporting Total Payment Obligation to Claimant (TPOC) to CMS through a sophisticated web portal.
During the teleconference, CRC discussed internal development in processing recovery of claims. Regarding past issues with unrelated diagnosis codes being included in conditional payment notices and letters, CRC advised the “grouper,” which was providing the unrelated treatments, was adjusted and is now providing summary forms (showing payments made by Medicare) with improved accuracy. The manual oversight of the summary forms is still being conducted to monitor the accuracy of the recovery letters. However, resources for the grouper oversight are being reduced based upon the improved accuracy. CRC also advised that it is “caught up” on their processes except for post initial determination replies.
Time Frames: Additionally CRC advised its target time-frames for responding to certain requests:
- 45 days to provide conditional payment information when proper authorization is on file and CRC has the lead information to develop the file
- Reply to Conditional Payment Notices within 30 days
- Reply to Conditional Payment Letter within 45 days
- Reply to post determination dispute within 60 days
- Acknowledge reimbursement of conditional payments within 20 days.
Intent to Refer to U.S. Treasury for Collections: If conditional payments are not reimbursed to Medicare and there is no pending appeal, CRC will refer the debt to collections by the U.S. Treasury Department. The CRC has advised that it will send an intent to refer a debt to collections by the U.S. Treasury department letter as a reminder to itself and the parties there is an outstanding balance related to a claim. These are commonly referred to as “intent to refer” letters. If an intent to refer letter is received, a response should be prepared. A carrier/employer should review the correspondence as this may be an indication that an appeal was not received or an appeal was decided without proper notice by CMS. In the circumstances of accepted claims, reimbursement may have not been received or processed properly.
Web Portal: The CRC highlighted additional functions that will be available in the first quarter of 2017 through the Medicare Secondary Payer Recovery Portal (MSPRP). This included the addition of information regarding conditional payment balance and refund status. Further, the web portal can be used to file an appeal of the initial determination and obtain status updates regarding the redetermination.
Authorization: The CRC encouraged the industry to use the web portal to upload authorizations and to use the web portal to obtain status updates regarding disputes and pending appeals. Authorization for a vendor or third party to communicate on behalf of an applicable plan must be provided on each claim. Additionally, the CRC stressed the importance of proper authorization. Specifically, the CRC advised that in situations where there is a settlement of the liability or workers’ compensation claim and the TPOC is reported to CMS, the BCRC will list the beneficiary as the debtor and request reimbursement from the beneficiary. This process requires special attention by the industry and authorization from the beneficiary in order negotiate the payments made by Medicare will be required.
BCRC will also pursue recovery from the beneficiary when the parties use the final demand and dispute process available on the web portal. This process allows the parties to the claim to obtain a final demand prior to settlement, but involves a highly coordinated process requiring approval of settlement three days from downloading CMS final demand and providing settlement within 30 days thereafter. If the parties do not meet the entire requirements of the process, the downloaded final demand is invalid. Additionally, this process may only be attempted once per claim.
Helpful Tips by CRC: At the end of the presentation, CRC provided some helpful tips in order to allow CRC to process conditional payment searches efficiently:
- Accurate section 111 reporting, including proper ICD9 and ICD10 codes, initiation and termination of ORM
- Sending correspondence to CRC’s proper address
- Attaching letters of authorization to any documents submitted to CRC
- After a TPOC report, the case goes to BCRC and correspondence is sent to the beneficiary and may not be sent to the applicable plan. Authorization from the beneficiary is needed to negotiate conditional payments.
One important take away from CRC’s presentation is the importance of proper authorization by the applicable plan, section 111 reporting entity, the beneficiary, the third party administrators, and MSA vendors in order to expedite and resolve payments by Medicare that require reimbursement. If possible, such terms to cooperate should be included into a claim’s settlement discussions.
Regardless of whether BCRC is pursuing reimbursement for conditional payments against the beneficiary, the Medicare compliance industry as a whole must keep in mind that Medicare is allowed to pursue collection against the applicable plan if the beneficiary does not reimburse Medicare. Therefore, although BCRC may be addressing the beneficiary, the applicable plan is still at risk for reimbursement. We will keep you posted with any further developments.