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 CRC should not search and collection.

BCRC searches and collects based upon settlement, judgement or award reporting. This is also reported through the claims system.  This event is generally referenced in the industry as TPOC reporting (Total Payment of Obligation to Claimant). This is independent from CRC’s collection process based upon ORM reporting.

This system by Medicare limits that data that is received by Medicare and excludes facts, such as: disputed conditions, utilization review and independent medical examinations.  Because of this situation, Medicare will run a search potentially using information that does not represent the entirety of the claim and results in overly broad collection requests. What Medicare does not tell you in its demands is that the section 111 user guide states the following with respect to ORM:

Reporting for ORM is not a guarantee by the RRE that ongoing medicals will be paid indefinitely or through a particular date; it is simply a report reflecting the responsibility currently assumed. Ongoing responsibility for medicals (including a termination date, where applicable) is to be reported without regard to whether there has also been a separate settlement, judgment, award, or other payment outside of the payment responsibility for ongoing medicals.

This means that there are many situations where Medicare is seeking reimbursement for charges associated with a claim, but the charges do not require reimbursement under the Medicare Secondary Payer Act.  Medicare does not tell you in its demands that Federal Regulations 42 C.F.R. 411.40(b)(2) states the following:

If the payment for a service may not be made under workers’ compensation because the service is furnished by a source not authorized to provide that service under the particular workers’ compensation program, Medicare pays for the service if it is a covered service.

Medicare recently provided a town hall presentation that also touched upon these circumstances. In additional to filing an appeal within the appropriate time frame and format, if you are disputing charges based upon non-covered services, Medicare recommends providing the following:

  • Copy of plan documents or other documents demonstrating that the services are not covered
  • Payment ledger showing that the dates of services were denied that shows: date of services, total amount billed, provider name date processed/payment was denied and denial code/reason stating services were not covered.

What is problematic about these statements from Medicare is that there are many times where the claimant or beneficiary is obtaining treatment without any notification or request for payment from the carrier/self-insured.  This means Medicare’s demand may be the first time the carrier/self-insured is faced with the bill for treatment.  It is in these circumstances the applicable plan my not have the exact documentation requested by Medicare. 

For these circumstances, we have had success by providing Medicare with payment screens and authorized medical records. These documents in correlation with Medicare’s payment summary form show (1) who the authorized providers are in the claim; and (2) the Medicare payment summary form does not match the authorized providers.

There are more pragmatic issues that place the burden, costs and time on carrier/self-insured to defend Medicare’s collections. For example: Medicare refers debts to U.S. Treasury for collection when there is an outstanding balance and despite there being 180 days from receipt of the redetermination to appeal. This creates a situation where U.S. Treasury is collecting or garnishing money before the time to file an appeal expires. This costs additional time and resources for Medicare and the debtor to secure a refund with a favorable decision.

These issues are being brought up with Medicare on a regular basis. We are hopeful there will be changes in the future that create practical and efficient reimbursements to Medicare.  As updates come in, we will keep you posted.