A Look at the NGHP Conditional Payment Recovery Transition to the Commercial Repayment Center

The Centers for Medicare and Medicaid Services (CMS) transitioned a portion of their Non-Group Health Plan (NGHP) conditional payment recovery work to the Commercial Repayment Center (CRC) as of October 5, 2015. The Benefits Coordination and Recovery Center (BCRC) remained responsible for the conditional payment recovery involving NGHPs in actions that were initiated prior to October 5, 2015. The transition to the CRC occurred several months after CMS implemented a direct right of appeal for conditional payment recovery actions directed towards an “applicable plan”. The direct right of appeal, mandated by the SMART Act, was effective as of April 28, 2015.

The transition of the NGHP conditional payment recovery work to the CRC has been less than smooth at times. Although CMS’ October 5, 2015 Alert regarding the transition to the CRC noted it was intended to improve claims payment accuracy in MSP situations, the CRC has been plagued with:

  • data migration errors
  • workflow process breakdowns
  • miscommunication of file information to clients
  • extreme delays in processing conditional payment notifications
  • conditional payment notices that include multiple charges unrelated to the reported injury
  • appeals to these erroneous charges being denied without a formal review
  • final demands being generated when disputes are pending review and determination

The ripple effect of the struggling contractor’s problems has been felt by many in the MSP community. These issues and possible solutions have been the subject of numerous recent discussions between the NuQuest team and the CRC management team. In discussions with the CRC, we were advised that:

  • The overly broad conditional payment notices were due to an error in their Tier 2 filter setting. This has since been corrected, and all new conditional payment notices will be given an additional review by CRC’s quality control analysts.
  • Conditional payment notices and demands that have already been sent should be disputed through the direct appeal process. We have been assured that going forward; CRC’s review of the disputes will be thorough.

We will continue in our efforts to resolve issues with the CRC by meeting with them regularly and will keep you posted.

Leave a Reply