Author Archives: PCzuprynski

a medical device over hundred dollar bills

Interplay: Section 111 Reporting and Conditional Payments

The Medicare Secondary Payer Act (MSP) and Medicare’s Section 111 User Guide require a carrier/self-insured to report to Medicare, when appropriate: Ongoing Responsibility for Medical (ORM); OR Settlement, judgement, award or other payment These requirements allow Medicare to perform three actions when presented with a medical payment that may be associated with a workers’ compensation, […]

Is your conditional payment negotiation game up to speed?

There are two entities initiating the recovery of conditional payments for Medicare Part A and B: Benefits Coordination Recovery Center (BCRC) and Commercial Repayment Center (CRC).  CRC collects based upon Ongoing Responsibility for Medical (ORM) reporting entered through the claims system from a carrier/self-insured (or their TPA). In denied cases where ORM is not reported […]

Section 111: What is Medicare missing?

Workers’ compensation and liability insurance carriers have the obligation to report two essential events if a claim involves a Medicare Beneficiary: Ongoing Responsibility for Medical (ORM) Settlement, judgment, award, or other payment Medicare refers to a settlement, judgment award, or other payment as “Total Payment Obligation to Claimant (TPOC).” These two events require the carrier/self-insured […]

Picture of a gavel

Downstream Actors May Have a Right to Reimbursement

Downstream Actors May Have a Right to Reimbursement: MSP Recovery Claims v. Ace Am. Ins. Co, 2020 U.S. Dist. Lexis 28610 In Ace, the U.S. Court of Appeals for Eleventh Circuit reversed a District Court’s decision and determined that a “downstream actor” from a Medicare Advantage Organization (MAO) had the right to seek reimbursement under […]

Medicare Advantage Organization Seeks More than Double Damages

Medicare Advantage Organization Seeks More than Double Damages: Aetna Life Ins. Co. v. Guerrera, 2020 U.S. Dist. Lexis 139949 In Aetna Life Ins. Co. v. Guerrera, the U.S. District Court for Connecticut determined that a liability insurance carrier was responsible for conditional payments associated with a settlement with a Medicare beneficiary. In the circumstances of […]

CMS Provides Webinar: Section 111 Non-Group Health Plan (NGHP)

August 17, 2020 by Patrick Czuprynski  On 8/13/2020, CMS provided a webinar and PowerPoint presentation to highlight and refresh stakeholders regarding certain aspects of Section 111 reporting and the recommendations outlined in the MMSEA Section 111 User Guide. It is important to understand that CMS is using the carrier/self-insured (or their TPA) claims system reporting […]

Conditional Payments in Review: 2018

In February of 2018, we saw a new contractor operating Medicare’s Commercial Repayment Center (CRC), Performant Financial Corporation.  As expected, there were growing pains or learning curves experienced with the new operator, such as: inappropriate referrals to U.S. Treasury for collection, letters of authorization inappropriately denied, statement of reimbursement forms not matching decision letters and […]