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.