CMS announces modification of its conditional payment recovery process

CMS announced today that it will be transitioning a portion of the Non-Group Health Plan (NCHP) recovery work from the Benefits and Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC) as of October 2015. The CRC has been responsible for all Group Health Plan (GHP) recovery activity since May of 2013. This division of labor is likely to result in an increase in conditional payment recovery claims against liability insurers, no-fault insurers and workers’ compensation plans.

The CMS update on this notes the following:

“Effective October 2015, the CRC will assume responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity as the identified debtor.

The following should be noted regarding the planned workload transition:

  • The transition only includes those cases where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly.
  • Beneficiaries and their attorneys will continue to work with the BCRC where CMS is pursuing recovery from the beneficiary.
  • Webinars and town halls will be scheduled in the coming months to provide additional information.

Effective January 1, 2016, CMS will add an additional limitation to Medicare claims payments where insurers or workers’ compensation entities have reported to CMS that they have Ongoing Responsibility for Medicals (ORM).

In situations where an insurer or workers’ compensation entity has reported to CMS that it has ongoing responsibility for medicals (ORM) for specific care, CMS’ claims processing contractors will use the information provided by the insurer or workers’ compensation entity to determine whether Medicare is able to make payment for those claims.

Insurers and workers’ compensation entities that notify Medicare that they have ORM are strongly encouraged to report accurate ICD-9 or ICD-10 codes. Medicare’s claims processing contractors will use this information to pay accordingly.”

We will keep you advised of further developments as they arise.

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