On 8/16/2018 at 1:00 PM EDT, the Centers for Medicare and Medicaid Services (CMS) will be presenting an “Overview Webinar” on its Medicare Secondary Payer Recovery Portal (MSPRP). The MSPRP is a useful tool in assisting parties regarding the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC)’s collection of conditional payments. Click here to be directed to the notice.
Once BCRC has been notified of the settlement, judgment or award (TPOC), BCRC will generally issue Medicare’s final lien with respect to the claim’s settlement.
This process above should not be confused with the Commercial Repayment Center’s (CRC) separate collection for Ongoing Responsibility of Medical (ORM) reporting. CRC’s notice and initial determination process is not a final lien from Medicare. If ORM has been reported or terminated, CRC may issue a separate collection against the carrier or self-insured based upon the ORM reporting. In certain circumstances both companies CRC and BCRC may initiate collection over the life of the claim.
It is important to remember that, at this time, the MSPRP only provides information with respect to payments made under Medicare Part A and Part B. There is yet to be a mechanism requiring CMS to advise its Part C and Part D partners that it has been notified of a TPOC or ORM reporting, legislators are trying to impact this issue through the Provide Accurate Information Directly Act, “PAID Act”, H.R. 5881.
A follow up will be posted after the 8/16/18 presentation.
Conditional payment collections can occur under various circumstances in non-group health plan claims and can leave parties bewildered regarding how and when an appeal can be filed. The audience will be provided with outline of appeal process and time frames, effective defenses and case studies of successful conditional payment negotiations with Medicare.
Register here to join us on Wednesday, August 1st at 3:00 PM (EST) with Patrick Czuprynski, Director of Lien Resolution.
In 2017, NuQuest received 1,933 conditional payment negotiation responses. 1,892 of these responses resulted in a reduction of Medicare’s reimbursement amount.
This means NuQuest limited Medicare’s conditional payment reimbursement amount 98% of the time in 2017.
There are two entities initiating the recovery of conditional payments paid under Medicare Part A and B: Benefits Coordination Recovery Center (BCRC) and Commercial Repayment Center (CRC).
BCRC is generally responsible for obtaining reimbursement for payments after a Total Payment of Obligation to Claimant (TPOC) is reported to Medicare. A TPOC is usually a settlement, judgment or an award. BCRC can collect against any party after settlement, but in most circumstances will seek collection directly from the Medicare beneficiary. CRC, on the other hand, is responsible for collection based upon Ongoing Responsibility of Medical (ORM) reporting. CRC will only collect against a carrier or self-insured with respect to ORM reporting.
There are many circumstances where reimbursement to Medicare for conditional payments is not required under the Medicare Secondary Payer Act. 2017 started with a declaration by the Central District of California’s Federal District Court that Medicare’s practice of collecting conditional payments, simply because one related diagnosis code was mixed with many other unrelated codes, was unreasonable and unenforceable. See California Insurance Guarantee Association v. Sylvia Mathews Burwell, et. al., 2:15CV01113ODW (“CIGA”). This declaration also advised that prima facie evidence can shift the burden to Medicare to justify its reimbursement.
In addition to the CIGA defense above, NuQuest has developed a variety of arguments that shift the burden to Medicare (BCRC or CRC) to justify its reimbursement request. If Medicare has no justification for reimbursement, Medicare will generally remove the inappropriate charges requested in its recovery.
We currently are experiencing a 100% success rate in 2018 and hope to continue to restrict Medicare’s reimbursement to amounts that are required under the Medicare Secondary Payer Act. We will keep you updated as we continue to track Medicare’s collection efforts.
Medicare awarded Performant Financial Corporation the contract to operate the CRC beginning 1/9/2018. The CRC works on behalf of Medicare where Ongoing Responsibility for Medical (ORM) has been reported. A carrier or self-insured may be required under the federal law to report to Medicare that it has accepted and/or terminated responsibility for certain diagnosis associated with a workers’ compensation or liability claim, called ORM reporting. The CRC may seek recovery for payments made by Medicare against the carrier or self-insured using this information.
Performant Financial Corporation is already a Medicare Recovery Audit Contractor (RAC) and has sought collection of outstanding conditional payment debts on behalf of the U.S. Treasury. In light of these circumstances, we are hopeful for a smoother transition from 2015 when CGI Federal began its operations of the CRC. However, we are anticipating an increase in the number of collection letters issued by the CRC for 2018 and are prepared for such a rise in collection efforts.
CRC should not be confused with the Benefits Coordination and Recovery Center (BCRC) who generally collects against claimants based upon reporting of Total Payment of Obligation to Claimant (TPOC). TPOCs are usually settlements reported to Medicare. If BCRC seeks collection against the claimant based upon TPOC reporting and payment is not made within 60 days, the federal regulations allow BCRC to seek reimbursement from the carrier or self-insured making the TPOC payment.
We will keep you advised on the transition as more information is available.
Performant Financial Corporation announced on October 5, 2017, that it was awarded the Medicare Secondary Payer Commercial Repayment Center (CRC) contract for identifying and recovering conditional payments in 2018. Performant has significant experience in assisting government organizations in the prevention and recovery of improper payments. Having served as a Recovery Auditor for CMS in the past, we expect a smooth transition between the current contractor, CGI and Performant in January of 2018. We will keep you advised of further developments.