Medicare’s Failure to Send Initial Determination to Carrier/Self-Insured – Collection by U.S. Treasury and Their Agencies

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NuQuest has recently observed an increase in calls and letters from collection agencies that are seeking reimbursement for alleged outstanding conditional payments made by Medicare. In discussing the increase with one of the collection agencies, NuQuest was advised that companies using a vendor to report their Section 111 information may not have been properly sent a copy of Medicare’s initial determination and a copy was only provided to the Section 111 vendor.

This means if a carrier or TPA receives a call or notice from a collection agency for outstanding conditional payments and did not receive the initial determination, the letter may have only been sent to the Section 111 vendor.  In these circumstances, it is recommended the carrier of self-insured contact its Section 111 vendor to determine if they received a collection letter from Medicare regarding the underlying claim and obtain a copy.

Collection calls and letters for a particular claim should stop when either arrangement of payment has been made or the collection agency is on notice of a pending appeal. Do not send payment to a collection agency without first receiving confirmation in writing of the collecting agency’s legitimacy and the legitimacy of the underlying debt. If the carrier or TPA is arranging payment, the carrier or TPA should contact the collection agency directly to do so. Payment is not an waiver of appeal of conditional payments.  If a favorable decision is obtained after payment, Medicare usually issues a refund within 30-60 days.

If there is a pending appeal on file with Medicare over the debt, a copy of the pending appeal letter should be sent to the collection agency. In this circumstance, if NuQuest is handling the conditional payment negotiation and is notified of the collection agency’s involvement, NuQuest will automatically send a copy of pending appeal letter directly to the collection agency.  This should put a stop to any collection calls or letters until a decision is issued.

If there is not an appeal on file, NuQuest may still be able to obtain a favorable outcome through its conditional payment negotiation services.  This is because a direct appeal, a request for extension or request for a revised initial determination may be a viable option. Once NuQuest receives the initial determination or intent to refer correspondence, and an appeal is filed with BCRC/CRC, a copy will be also be faxed to the collection agency.  This should also put a stop to the collection calls.

If the collection calls or letters do not stop and payment has been arranged or the agency is on notice of appeal, the collection efforts could be a violation of debt collection law. NuQuest is a Medicare Secondary Payer Compliance vendor and does not represent customers in fair debt collection practices act litigation. If there is an issue with ongoing collection calls, contacting a supervisor or attorney who practices law in this area is recommended.

If you have any questions or would like to set up a time to discuss conditional payment issues with our Director of Lien Resolution, Patrick Czuprynski, please contact him at pczuprynski@mynuquest.com