April 7, 2021
Leaders from the Centers for Medicaid and Medicare Services (CMS) Division of MSP Program Operations, Commercial Repayment Center (CRC), and Benefits Coordination and Recovery Center (BCRC) held an April 1 webinar on the intersection of the BCRC and CRC in Section 111 Mandatory Insurer Reporting and the resolution of Medicare conditional payments.
While mostly a Q&A format, the webinar unveiled a new CMS/BCRC policy for reporting partial settlement of medical when Ongoing Responsibility for Medical (ORM) ends for certain diagnoses and continues for others. Set to rollout in June, the new reporting policy provides for three scenarios:
- Partial settlement of medical prior to initial reporting
Scenario: Claimant is identified as a Medicare beneficiary which triggers the requirement to report ORM and/or Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process. Both ORM and TPOC are for the same insurance type, policy, and claim number. The only difference is the accepted and denied diagnoses on the claim. The parties agree to a partial settlement for the denied diagnoses and leave the accepted diagnoses open on the claim.
Problem: How to report a partial settlement of the denied diagnoses and still report ORM for the accepted diagnoses.
CMS Solution: CMS’s solution is to submit two add records. Specifically, one record will be added for ORM that will describe all of the diagnoses that have been accepted for ORM. ORM will be ‘Y’ with no TPOC date or amounts. A second record will be added for TPOC which will describe all of the denied diagnoses that are being settled. ORM will be ‘N’ with a TPOC date and amount.
- Partial settlement of medical post initial reporting
Scenario: A claim with multiple diagnoses was reported for ORM through the Section 111 Mandatory Insurer Reporting process. The parties agree to a settlement for certain diagnoses while keeping ORM open for other diagnoses.
Problem: How to report a partial settlement for certain diagnoses while keeping ORM open for the non-settled diagnoses.
CMS Solution: CMS’s solution is to submit one update record and one add record. The update record will remove the diagnoses that are subject to the partial settlement and keep the diagnoses codes where ORM continues. Then, an add record with the TPOC date, amount and diagnoses codes that are subject to the partial settlement will be submitted. ORM will remain “N” in the add record.
- Partial ORM closure with no settlement
Scenario: Acceptance of ORM is initially reported though the Section 111 Mandatory Insurer Reporting process with multiple diagnoses. Subsequent to this initial report, there is a basis to terminate one or more of the initially accepted diagnoses, but not all of the diagnoses. This is not a situation where a partial settlement has occurred, rather there is a basis to terminate one or more diagnoses absent a settlement. For example, a claimant’s cardiac condition was exacerbated as a result of a fall and the medical providers confirm resolution of the exacerbation. While the carrier continues to accept the orthopedic condition, the ORM can end for the cardiac diagnosis.
Problem: How to end ORM for one or more diagnoses while keeping it open for other diagnoses.
CMS Solution: CMS’s solution is to send an update record that removes the diagnosis or diagnoses where ORM has ended. In this situation a TPOC date is not submitted, rather this is only submitted when ORM is completely terminated for all diagnoses.
The purpose behind these new policies is to improve coordination of benefits such that a Medicare beneficiary’s medical care is not denied when unrelated to a claim and prevent the recovery contractors from attempting to seek reimbursement for Medicare payments unrelated to a claim.
While we thank CMS and the BCRC for identifying solutions to the above reporting problems, we believe RREs may face some technical challenges in the ability to, for example, report two add records on the same claim. We await issuance of the formal policy from CMS and will review how this policy change can best be incorporated into the Section 111 reporting process.
In addition to announcing the new reporting policy, CMS and the contractors provided the following advice:
Respond to correct contractor – Carefully review the correspondence and make sure to respond to the contractor that sent the letter, whether it’s to obtain further information, dispute/appeal charges, or to make payment.
As a reminder, CMS noted, the BCRC is generally recovering conditional payments when the identified debtor is the Medicare beneficiary while the CRC is recovering conditional payments when the insurer/WC carrier is the identified debtor.
CMS provided the following guidance regarding key timeframes:
- Interest accrues from the date of the demand letter and is assessed on debt if not resolved within 60 days.
- When CMS issues a demand letter directly to the applicable plan, the applicable plan has formal administrative appeal rights.
- The applicable plan has 120 days from the date the applicable plan receives the demand letter to file a redetermination (first level of appeal). Interest will still accrue during this time.
- If the appeal is not filed within 120 days, and “good cause” for untimely filing is not provided, the appeal will be dismissed.
- Failure to resolve the debt will result in referral to treasury at 180 days.
Note: When you are appealing to the ALJ please be sure to cc the CRC so that they can appropriately place a hold on a case so that it is not referred to treasury while the appeal is in process.
During the Q&A portion of the webinar CMS and its contractors addressed varied questions; some are summarized below:
- What can be done if we cannot obtain a Social Security number from the claimant? CMS advised them to document their efforts at obtaining the SSN. It was noted CMS has model language found on the CMS website which can be used to document claimant’s refusal to provide SSN.
- In response to a question concerning the many charges found on conditional payment notices and demands that are unrelated to the injury, CMS/CRC acknowledged that it is not a perfect process. The CRC explained that when conditional payment information is requested what is sent to the requestor may have only been produced through an automated search of charges related to the injury. CRC did advise that when it comes to actual issuance of a demand that there is a human validating process.
- In response to a question concerning why in response to a dispute of a Conditional Payment Notice, one might receive another CPN with new charges, the CRC explained that this is the result of the system constantly reviewing for additional charges deemed related to the injury.
- There were several questions regarding problems with the CRC recognizing out-of-pocket reimbursements to claimants in a no-fault/med-pay claim as counting towards the exhaustion of the no-fault maximum amount. CRC’s response was to advise entities to provide plan documents and proof of payment to the claimant along with a reason for the payment. Its leader said, “We are aware that no-fault payors have run into problems with CRC rejecting out-of-pocket expenses as included within the no-fault exhaustion amount.”
If you have any questions, please contact Tower’s Chief Compliance Officer, Dan Anders, at email@example.com or 888.331.4941.
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