Medicare hosts Town Hall 1/14/2020: Non-Group Health Plan

January 16, 2020 –

On 1/14/2020, Medicare hosted a town hall meeting to explain certain aspects of its collection process and also set time aside for a Q&A session.

During the presentation, Medicare provided information regarding:  Medicare’s collection process using Section 111 reporting information, CRC’s optional Pre Conditional Payment Notice process and the open debt feature on the Medicare Secondary Payer Recovery Portal.

Medicare’s collection process using Section 111 reporting information: There are two entities initiating the recovery of conditional payments for Medicare Part A and B payments: Benefits Coordination Recovery Center (BCRC) and Commercial Repayment Center (CRC).

CRC collects based upon Ongoing Responsibility for Medical (ORM) reporting entered through a carrier/self-insured or TPA’s claims system. In denied cases where ORM is not reported CRC should not search and collection.  However, as discussed by Medicare, there may be times where CRC will provide a conditional payment estimate, based upon the conditions expected to be released in an upcoming settlement when ORM has not been reported.

BCRC searches and collects based upon settlement, judgement or award reporting. This is also reported through a carrier/self-insured or TPA’s claim 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. In most cases and confirmed during the town hall, BCRC will seek reimbursement directly from the claimant after settlement of liability and workers compensation claims. This is regardless if the carrier/self-insured agrees to negotiate and reimburse settlement. Due to privacy rules, this can pose a problem if the carrier agrees to negotiate and reimburse the search based upon settlement reporting. This is because the claimant must complete a proof of representation in order to dispute charges.

Additionally, if payment is not made within 60 days, BCRC also has the ability to start referral to U.S. Treasury process or seek collection against the carrier or self-insured who settles the claim.

Pre Conditional Payment Notice Process: A carrier or self-insured can contact Medicare and ask for a list of cases that Medicare expects to send a Conditional Payment Notice letter on. If a case is on the Pre-CPN list, the customer would want to review the section 111 reporting associated with the claim to make sure it is accurate and complete.  If there is a discrepancy in the reporting or the claim should not have been entered into the section 111 system, the carrier/self-insured has an opportunity to correct these issues at pre-CPN stage. This process does not produce a payment summary form for a customer to identify if certain charges are associated with a claim.

The idea with this process is to make appropriate section 111 changes before Medicare runs its search and collection. However, as some have experienced in the industry, there are times where Medicare will send out its collections on the pre-CPN list without waiting for the Section 111 reporting to update.

Open Debt Feature: The open debt feature is located on the Medicare Secondary Payer Recovery Portal (MSPRP) and allows a carrier/self-insured to see if there are any outstanding Medicare conditional payment debts.  This option is available to account managers who have registered onto the MSPRP. However, an account manager is only able to obtain an open debt report associated with the Tax ID specifically used to register the account on the MSPRP.

This means a TPA or vendor is not able to obtain an open debt report for their customers (Carrier/Self-insured), unless the carrier/self-insured registers on the portal itself and distributes the report.

This issue has been brought to the attention of Medicare, but no update during the town hall was provided.  As this issue develops, we will provide additional information.

Q&A Session: Some important takeaways from this particular session were as follows:

  • If possible, support your arguments that reimbursement is not required with documentation.  For example: if you are arguing exhaustion of benefits, provide demonstration of payments exhausting benefits.
  • Statute of Limitations:  42 USC 1395y(b)(2)(B)(iii) pertains to Medicare when it files suit in federal court to recover payments, this statute of limitations does not apply to Medicare’s administrative process and U.S. Treasury’s administrative collections.  This particular statute only applies in the even Medicare files suit in court for reimbursement and that suit is after three years from notice of settlement, judgement, award or other payment
  • Medicare has little control over U.S. Treasury’s collection process.  For example, Medicare is not able to get U.S. Treasury to place additional information in their collection letters so a debtor can identify the associated claim.
  • The “grouper,” Medicare’s computer system that searches for potential charges for reimbursement is being reviewed internally and also by a third party contractor for accuracy problems.

We are hopeful to see Medicare make changes to its collection processes based upon the common nuances that affect stakeholders on a per claim basis. The open debt feature is one example of a swing and a miss by Medicare. Interestingly enough, there was no mention of Civil Money Penalties associated with section 111 reporting, discussed here.  The last notice on the proposed rule was pushed to December 2019, but nothing on these rules has been sent by Medicare. As more develops on conditional payments, we will keep you posted.