2015 CMS Highlights

CMS started the year off with the issuance of a February 27, 2015, final rule establishing
a right of appeal and formal Medicare Secondary Payer (MSP) appeal process for
applicable plans. This process was mandated by Section 201 of the SMART Act.
Applicable plans were defined as: liability insurance (including self-insurance), no-fault
insurance, and workers’ compensation plans. Implemented by CMS on April 28, 2015,
applicable plans were given a multi-level appeal process for the resolution of conditional
payment recovery demands issued directly to the plans. The appeal process includes: an
‘initial determination” of the conditional payment demand, a “redetermination” by the
contractor issuing the recovery demand, a “reconsideration” by a Qualified Independent
Contractor, a hearing by an ALJ, a review by the Medicare Appeals Council, and judicial

Claims with a reported Ongoing Responsibility for Medicals (ORM) were also targeted by
CMS for conditional payment recovery. This represented a significant departure from
CMS’ prior conditional payment recovery actions at the conclusion of a claim. In
addition, CMS did away with a procurement cost reduction in their recovery demands
issued directly to applicable plans.

On July 21, 2015, CMS rolled out its Multi-factor Authentication (MFA) services for use
on the Medicare Secondary Payer Recovery Portal (MSPRP). This service allows nonbeneficiary
users to access conditional payment information that was previously
unavailable through the portal. Access is available upon successful completion of the
Identity Proofing and MFA process requirements.

On October 1, 2015, CMS converted to the ICD-10 diagnostic and procedure code
system. The new coding system allows for greater specificity in the injury / condition
descriptions. This improved data collection is expected to impact evidence-based 
medicine research. It should also allow CMS to better target conditional payment
recovery claims. 

October also saw CMS’ transition of a portion of the non-group health plan recovery
workload to the Commercial Repayment Center (CRC). The CRC assumed responsibility
for new recovery claims where CMS is pursuing recovery directly from the liability
insurer, no-fault insurer or WC entity. Recovery actions directed towards the beneficiary
would continue to be handled by the Benefits Coordination and Recovery Contractor

CMS advised in its CRC webinar and training materials that a Conditional Payment
Notice (CPN) will be issued by the CRC to the applicable plan when it reports that it has
ORM in the claim. Payments identified in the CPN may be disputed once within 30 days
of the date of the CPN. Failure to dispute the CPN will trigger the issuance of a demand
letter or initial determination. Once this letter is issued, administrative appeal rights will
become available to the plan. A Conditional Payment Letter (CPL) is issued when a
beneficiary or his representative self-reports the claim and the MSP occurrence was not
otherwise reported by the applicable plan. Conditional payments noted in a CPL may be
disputed at any time.

On October 19, 2015, CMS announced the 2015 recovery threshold for physical traumabased
liability insurance settlements, judgments, awards or other payments remained at
$1,000.00 or less. This means that CMS will not seek recovery of conditional payments
in these physical trauma-based liability settlements of $1,000.00 or less and that entities
are not required to report these settlements.

Final Conditional Payment process functionality by January 1, 2016. This new process
will allow authorized MSPRP users to notify CMS within 120 days or less of an
anticipated settlement and request that the case be a part of the Final CP process. This
means that disputes regarding the conditional payment amount submitted through the
MSPRP will be resolved within 11 business days of receipt of the dispute. In addition, the
new process provides that the Final Conditional Payment Amount will be available on
the MSPRP after all the disputes have been resolved and within three days of the
settlement. This figure will remain the final figure as long as the case is settled within
three calendar days of requesting the Final Conditional Payment Amount. The
settlement information must also be submitted through the MSPRP within 30 calendar
days of requesting the Final Conditional Payment Amount. The new Final CP process
became available on December 21, 2015.