Recently, Medicare provided a webinar that touted increased functionality of the MSPRP. These additional functions may allow a party to request an “electronic” conditional payment letter (estimate), prior to an initial determination, but also will provide a view that shows the statuses of correspondences received and sent by Medicare associated with the case number. This feature also lets a party see if their correspondence has been received and is “open” (pending review) or “closed.” Medicare has provided a link to its presentation that can be found by clicking here.
What Medicare did not discuss in their presentation are the issues they are currently facing in properly training its employees to handle the multifaceted issues and correspondences surrounding conditional payment negotiation and resolution.
Failure to properly process appeal documents: Medicare is receiving an appeal of conditional payments, but there are employees for Medicare that are improperly closing the appeal without providing a decision. This means that, at times, Medicare will continue its collection processes as if the appeal was never received.
Another scenario involves when payment has been received by Medicare. If payment is made, but an appeal is filed, the appealing party is entitled to a reimbursement from the government in the event Medicare rules in favor of the appeal. The payment at the time of, before or after appeal, does not mean the appealing party has waived its appeal rights. Nevertheless, some employees at Medicare are improperly closing appeals when payment is received.
Failure to issue proper responses to appeals: Recently, Medicare has also started to issue “case resolved” letters. These letters are being issued by CRC wrongfully in response to an appeal of initial determination. Federal regulation 42 C.F.R. 405.956 requires Medicare to provide a “Notice of Redetermination” when it makes a decision on an appeal of initial determination. The notice of redetermination is required among other things to have specific information regarding appeal rights, explanation of the decision, etc. These items are not included in the case resolved letter and violate federal regulations with respect to redeterminations.
What this means for stakeholders:
- a greater need to understand what Medicare is or is not authorized to do under the Medicare Secondary Payer Act and regulations;
- more follow up with Medicare;
- continued attention to Medicare’s actions with negotiating and resolving conditional payments with Medicare; and
- demonstrates the importance of the carrier or self-insured enlisting a “recovery agent”
A possible solution to address the foregoing issues may be for Primary Payers to appoint a Recover Agent. Recovery agents (formerly identified as a third party administrator in section 111 reporting) are sent a carbon copy of all correspondences sent by BCRC or CRC that is directly sent to the carrier or self-insured. With the appropriate agent, the agent can support the carrier or self-insured in digesting and responding to the proper and improper correspondences from Medicare.
At this time, should you receive a case resolved letter, but have appealed the conditional payments, the letter may be indicative that Medicare failed to process the appeal properly and follow up may be required. NuQuest is working with Medicare to resolve this issue as quickly as possible.
More updates will be posted as they are available on these issues.