Medicare Conditional Payments Archives

Fixed Percentage Option Now Available for Liability Settlements up to $10,000

September 29, 2023

Picture of someone with a magnifying glass looking thru a book of papers for a Fixed Percentage Option to resolve Medicare conditional payments liability settlements of up to $10,000.

The Centers for Medicare and Medicaid Services recently announced that the maximum settlement amount for use of the Fixed Percentage Option will increase from $5,000 to $10,000, effective 10/2/2023. The Fixed Percentage Option is available to the claimant in a liability settlement and allows them to agree to pay 25% of the total settlement amount to resolve Medicare’s recovery claim for conditional payments. The criteria for selecting this option are:

Your liability insurance (including self-insurance) settlement, judgment, award or other payment is related to an alleged physical trauma-based incident and;
The total settlement is for $5,000 (Note this amount will be raised to $10,000, effective October 2, 2023) or less.
You elect the option within the required timeframe and Medicare has not issued a demand letter or other request for reimbursement related to the incident.
You have not received and do not expect to receive any other settlements, judgments, awards, or other payments related to the incident.

This option benefits the injured person when Medicare conditional payments exceed 25% of the total settlement amount. For example, if Medicare has made conditional payments of $8,000 on a $10,000 total settlement, the claimant would pay only $2,500 to resolve them with the Fixed Percentage Option. On the other hand, if conditional payments are $800 on a $10,000 settlement, it is better to use the traditional repayment method with a proportional reduction for attorney’s fees and costs, if any.

Accordingly, it is essential for claimants and their attorneys to investigate Medicare conditional payments prior to settlement so that they can choose the best method for resolving Medicare’s interests.

More information on the Fixed Percentage Option can be found on the CMS website here.

Please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com with any questions.

CMS News Roundup: New Conditional Payment Appeals Guide & Webinar on Section 111 Reporting

May 25, 2023

Red Medicare button on a keyboard to illustrate Medicare conditional payment.

The Centers for Medicare and Medicaid Services (CMS) recently released a how-to guide for appealing Medicare conditional payment demands. The Non-Group Health Plan (NGHP) Applicable Plan Appeals Reference Guide consolidates conditional payment rules and best practices that the agency has issued through webinars, slides and its website.

Section 2.0 gives a breakdown of the appeals levels and explains how to submit an appeal and authorization/letter of authority requirements. Section 3.0 details what can be appealed and supporting documentation. Section 4.0 lists additional resources. Finally, an appendix provides sample letters and model language for applicable plans to appoint recovery agents.

It is important to note that this guide does not cover Conditional Payment Notices (CPNs), which are issued before demand letters to allow the recipient 30 days to dispute the charges. However, the bases for CPN disputes are the same as those found in Section 3.0. When the dispute fails or is not timely, a demand letter is issued and the demand letter can be appealed, even with the same arguments used to dispute the CPN.

We appreciate CMS taking the time to draft and release this guide. It joins the WCMSA Reference Guide and the Section 111 User Guide as critical reference tools for anyone impacted by Medicare Secondary Payer compliance.

CMS Section 111 Non-Group Health Plan (NGHP) Unsolicited Response File Webinar

The Centers for Medicare and Medicaid Services (CMS) recently published a Section 111 reporting webinar notice for a webinar on June 6, 2023 at 1:00 PM ET and states:

CMS will be hosting a webinar regarding the upcoming implementation of the Section 111 NGHP
Unsolicited Response File option. The format will be opening remarks by CMS, a presentation that will include background as well as how to opt in and what to expect, followed by a question and answer session. For questions regarding this topic, prior to the webinar, please utilize the Section 111 Resource Mailbox PL110- 173SEC111-comments@cms.hhs.gov

As of July 2023, Responsible Reporting Entities (RREs) can opt-in to receive a monthly “NGHP Unsolicited Response File” via the Section 111 secure website. Per CMS, the file “will provide critical information about updates to ORM records originally submitted in the last 12 months and allow RREs to either update their internal data or contact the Benefits Coordination & Recovery Center (BCRC) for a correction.”

It is important for an RRE to review and confirm that the changes made by the BCRC and listed in this report are correct. If not, then the BCRC must be contacted to advise them that the RRE disagrees with the change made by the BCRC. We encourage anyone involved in managing Section 111 reporting to tune in. Please note that there is no pre-registration; the link and call-in numbers are on the notice. You log in shortly before the webinar’s start time.

CMS to Provide RREs with Response File on ORM Record Changes

Successful Appeal to CMS ALJ Yields $80K Reduction in Conditional Payments

March 15, 2023

Scrabble tiles spelling Appeal to use for Conditional Payments

In response to a Medicare conditional payment demand, payers can access a five-level appeals process, including a hearing before a Centers for Medicaid and Medicaid Services (CMS) administrative law judge (ALJ). Most conditional payment demand appeals are resolved at the first two levels: redetermination and reconsideration. However, some are escalated to an ALJ as happened in this case.

ALJ Appeal Success Story

On July 24, 2020, the Commercial Repayment Center (CRC) issued a demand for reimbursement of $149,902.98. The work injury had aggravated a pre-existing left knee skin graft, resulting in an infection of the left knee. The payer accepted the aggravation but not the long-term condition of the knee.

Charges on the demand were either completely unrelated to the left knee or for treatment deemed related to the longstanding pre-existing condition of the left knee. An appeal was filed, and the CRC redetermination decision stated that none of the charges would be removed.

At this point, a second-level appeal was filed with the Qualified Independent Contractor (QIC). CMS contracts with the QIC to provide an independent review apart from the CRC. Its March 26, 2021 reconsideration decision was partially favorable because almost all the charges related to body parts other than the left knee were removed from the demand. The revised demand was $79,489.97, which also included interest.

The next step was an ALJ appeal submitted on May 12, 2021. It can take two to three years to receive a hearing date, but in this case, it took a little over a year to receive a hearing date set for June 28, 2022.

The difficulty in this appeal is that after some initial treatment in the state where the injury occurred, the injured worker moved to another state where he received further treatment. The payer never received bills from the out-of-state medical providers whose charges were listed in the conditional payment demand. Fortunately, we could work with the defense attorney who subpoenaed the medical records. Unfortunately, upon review, the medical records were unclear on causation.

Nonetheless, we put our best argument forward at the hearing and through our brief to the ALJ that the work-related infection was a temporary aggravation of a long-standing condition of ulcers to both knees. This was supported by an inconsistent history from the injured worker and medical notes, which implied that the post-injury infection had resolved shortly after the accident.

What is helpful at the ALJ appeal level is that you can speak to the judge, explain your position and answer his or her questions. This differs from the first two levels of appeal, which come down to submitting the appeal and receiving a decision.

In a September 12, 2022 decision, the ALJ agreed with our position. As a result, the demand, which by then exceeded $80,000, was reduced to $441.19.

Keys to Appeal Success

Here is what made this appeal successful:

Appeals Deadline Met

All five levels of appeal have specific timeframes for an appeal submission. It is essential to file an appeal by the designated deadline which should also prevent the CRC from referring the debt to the Treasury Department for collection (assuming the debt is not paid during the pendency of the appeal).

In this case, our client had designated Tower as its recovery agent, which means we receive copies of letters and notices the CRC sends this client. As the recovery agent, we can immediately advise the client of a Conditional Payment Notice or Demand Letter, what it means, and the deadline for action. As a result, all appeals deadlines were met.

Cooperation Between Tower and Client

Successful conditional payment appeals are often based on medical records, Independent Medical Exams and utilization reviews, as well as legal documentation. It is imperative that the claims professional and defense attorney work with Tower to obtain the documentation necessary to support the appeal. In this case, the defense attorney’s diligent efforts at subpoenaing and then follow-up with the medical provider resulted in the timely receipt of the out-of-state medical records.

Knowledge and Experience with Conditional Payment

In addition to having supporting documentation, the appeal must provide an acceptable basis for why the charges should be removed from the demand. Tower’s team of professionals has the knowledge and experience to combine the facts and law to make successful arguments to the CRC and QIC. Additionally, any matter appealed to the ALJ will be handled by Tower’s Chief Compliance Officer, Dan Anders, who has two decades of experience in Medicare Secondary Payer compliance, including prior successful ALJ appeals, as exemplified in this case.

Whatever your conditional payment scenario, we stand ready to assist. Learn more about our conditional payment services here, where you can also refer a matter for handling.

CMS to Hold Webinar on “Go Paperless” Feature in MSPRP

March 28, 2022

On April 13, 2022, at 1:00 pm ET, the Centers for Medicare and Medicaid Services (CMS) will host a webinar on the “Go Paperless” option in the Medicare Secondary Payer Recovery Portal. The selection of this option will provide for more expeditious receipt of correspondence from the CMS Medicare conditional payment recovery contractors. Per the announcement:

The Centers for Medicare & Medicaid Services (CMS) will be hosting an overview of the new “Go Paperless” feature available in the Medicare Secondary Payer Recovery Portal (MSPRP). Insurers and authorized agents may now choose to opt-in to paperless functionality. Once registered, users will be able to quickly and easily access all recovery correspondence including demand letters, using the MSPRP. Opting to “Go Paperless” in combination with the ability to submit correspondence through the MSPRP and the multiple available options for electronic payment will allow your organization to not only reduce the amount of paper that needs to be physically handled, associated workload and environmental impacts, but also eliminate concerns about delays that can arise when information is sent through the mail.

The webinar will feature opening remarks and a presentation, followed by a question-and-answer session.

Note, there is no pre-registration, instead, just follow the provided link shortly before the webinar start time.

By way of background, in January CMS released an updated Section 111 User Guide, Version 6.7, which in Chapter V provides as follows:

When there is an active Medicare Secondary Payer Recovery Portal (MSPRP) account for the insurer/recovery agent TIN, Section 111 submitters may set Go Paperless options (i.e., choose to receive letters electronically or by mail) for the insurer and recovery agent address using the following new TIN Reference File fields (Appendix B):

TIN/Office Code Paperless Indicator (Field 23)
Recovery Agent Paperless Indicator (Field 24)
Recovery Agent TIN (Field 25

Note: There are also five new fields (Fields 48-52) returned for these entries on the TIN
Reference Response File (Appendix D).

Along with the updates to the Section 111 User Guide, CMS also updated the Medicare Secondary Payer Recovery Portal (MSPRP) User Manual, Version 5.3, to incorporate functionality around the Go Paperless option.

Key Takeaways

We are pleased to see CMS provide this Go Paperless option for Responsible Reporting Entities (RREs) and their authorized agents. It is environmentally friendly and will allow time-sensitive correspondence i.e., Conditional Payment Notice with a 30-day due date, to be received and acted upon sooner.

If you are interested in taking advantage of the Go Paperless option or have other questions we encourage you to attend the CMS webinar. Also, you can always contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or daniel.anders@towermsa.com with any questions.

CMS Rolls Out ACH Payment Option for Recovery Debts

February 23, 2022

The Centers for Medicare and Medicaid Services now provides ACH payment option for Medicare conditional payment debts.

The Centers for Medicare and Medicaid Services (CMS) is now accepting recovery debt (Medicare conditional payment recovery) payments via ACH (Automated Clearing House) transactions. CMS’s February 18, 2022 announcement says this applies to Non-Group Health Plans (NGHP) as well as Group Health Plans (GHP).

Employers, insurers, third-party administrators, attorneys, and plan sponsors can send payments electronically to the Commercial Repayment Center (CRC) or Benefit Coordination & Recovery Center (BCRC) for processing. ACH setup must be coordinated with the CRC and/or BCRC.

The CMS announcement states:

“ To begin sending payments using ACH, please send an email to the appropriate email address below with “ACH Set Up” in the subject line. Be sure to include a specific point of contact with your organization for the CRC or BCRC. The BCRC/CRC will reach out directly to get the process started.

For the CRC: Please submit an e-mail to CRCACHpayments@performantcorp.com

For the BCRC: Please submit an e-mail to BCRC_Finance@GDIT.com “

Practical Implications

The ACH payment option means that CMS is now allowing payers to provide their bank account routing and account numbers to facilitate payment of Medicare conditional payment debts. This is a benefit to the payer in not only avoiding the cost of a postage stamp but to having a quick electronic confirmation of receipt of payment. This can avoid a “lost in the mail” or a late payment situation which can result in the imposition of interest charges from Medicare.

If you have any questions, please contact Dan Anders, Chief Compliance Officer, at 888-331-4941 or daniel.anders@towermsa.com.

Questions About Medicare Conditional Payments? Join Our Upcoming Free Webinar

March 10, 2021

Man in business suit looking confused about Conditional Payments

When it comes to Medicare conditional payments, we get questions! We’re commonly asked about CMS Medicare conditional payment policies, practices of CMS recovery contractors, the extent of Treasury Department debt recovery and more. It’s important to get the right answers because resolving Medicare conditional payments should be standard practice when settling a workers’ compensation or liability claim involving an injured worker who is a Medicare beneficiary. If you have questions like these:

When and how to communicate with the Commercial Repayment Center (CRC) vs. the Benefits Coordination and Recovery Center (BCRC).
Requesting and reacting to Medicare conditional payment recovery correspondence.
Dispute and appeal conditional payments: What works, doesn’t work and sometimes works.
Resolving Treasury Department debt recovery actions

… why not join us for our free webinar Medicare Conditional Payment Tune-up next week? We’ll be holding a Q&A session after the presentation. Here are the details – be sure to scroll down and click our sign-up button!

$750 Medicare Conditional Payment Recovery Threshold Remains for 2021

CMS Introduces Pre-CPNs and Open Debt Reports in Conditional Payment Recovery Process

CMS to Host Reporting and Medicare Conditional Payment Recovery Town Hall

March 2, 2021

The Centers for Medicare and Medicaid Services (CMS) recently announced it will be hosting a town hall on April 1, 2021 at 1 pm ET to discuss common Non-Group Health Plan topics. Specifically, representatives from CMS, the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC) will be on hand to answer questions related to Section 111 mandatory insurer reporting and Medicare conditional payment recovery.

Complete information can be found here.

In follow-up to Tower’s Medicare Conditional Payment Tune-up webinar, which will be held on March 18, CMS is providing an excellent opportunity to directly address questions with both the policymakers and the recovery contractors.

If your responsibilities touch on Section 111 reporting and/or Medicare conditional payment recovery, we encourage you to attend the town hall.

Medicare Conditional Payment Tune-up

February 26, 2021

Resolving Medicare conditional payments should be standard practice when settling a workers’ compensation or liability claim involving an injured worker who is a Medicare beneficiary. However, there are still many questions around CMS Medicare conditional payment policies, practices of CMS recovery contractors and the extent of Treasury Department debt recovery.

Join Dan Anders, Tower’s Chief Compliance Officer, on Thursday, March 18 at 2:00 PM ET, for a Medicare conditional payment “tune-up.” The free webinar will focus on:

When and how to communicate with the Commercial Repayment Center (CRC) vs. the Benefits Coordination and Recovery Center (BCRC).
Requesting and reacting to Medicare conditional payment recovery correspondence.
Dispute and appeal conditional payments: What works, doesn’t work and sometimes works.
Resolving Treasury Department debt recovery actions

Dan will also provide an explanation of the PAID Act and expectations for the implementation of its provisions over the course of 2021.

A Q&A session will follow the presentation. Please click the link below and register today!

Medicare Conditional Payment Recovery Threshold for 2021

December 1, 2020

chart, dollars and a fountain pen illustrating conditional paument recovery threshold post

In an 11/25/2020 Alert, the Centers for Medicare and Medicaid Services (CMS) announced that the 2021 conditional payment recovery threshold for liability, no-fault and workers’ compensation settlements will remain at $750. Accordingly, Total Payment Obligations to the Claimant, TPOCs, in the amount of $750 or less are not required to be reported to CMS through the Section 111 Mandatory Reporting process, nor will CMS attempt to recover conditional payments for TPOCs of this amount (The threshold does not apply to liability settlements for alleged ingestion, implantation or exposure cases).

By way of background, pursuant to the SMART Act of 2012, CMS is required to annually determine a threshold amount such that the cost of collection does not outstrip the amount recovered through such collection efforts. CMS’s calculations, which can be found here, resulted in maintaining the $750 threshold.

Practical Implications

As CMS is keeping the $750 threshold for mandatory reporting and conditional payment recovery there are no changes to the reporting processes or determinations as to when conditional payments should be investigated or resolved.

November CMS Mandatory Reporting and Conditional Payment Updates

November CMS News: Mandatory Reporting and Conditional Payment Updates

November 24, 2020

Hand writing What's New?" on a chalkboard for CMS news update

Here’s a recap of recently announced CMS news:

CMS News #1: Medicare Conditional Payment Appeals Guide

In follow-up to its September 2020 webinar on Medicare conditional payment appeals through the Commercial Repayment Center (CRC), CMS converted the slides into an appeals guide. The guide, which can be found here, provides a breakdown of the Medicare conditional payment appeals process and the bases for appeals.

CMS News #2: Updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Guide

Earlier in November, CMS released a Technical Alert and an updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting User Guide, Version 6.1, to announce “Section 111 Edits to no Longer Cause Record to Reject.”

In short, starting April 5, 2021, several error codes will be converted into what CMS calls “soft edits.” Soft edits are still considered errors by CMS but will not cause the entire record to be rejected. Examples of such data errors are in fields reporting middle initial of claimant’s name and alleged cause of injury. The Responsible Reporting Entity (RRE) is still responsible for correcting these errors in the next quarterly file submission.

Additionally, a new soft edit will be added and applied to NGHP Claim Input File Detail Record files when users submit a no-fault insurance claim where the policy limit is less than $1000.00. The input files will be accepted but a new CP13 error will be returned on the response files.

Finally, Claim Input File Detail Records submitted prior to the effective date of the injured party’s entitlement to Medicare will be rejected and returned with a Disposition Code ‘03’ instead of an SP31 error. As a result, if the purpose of the report was to indicate ongoing responsibility for medicals has been accepted (ORM=Y), then the claim will need to be re-submitted in the next quarterly reporting period (at which point the claimant is presumably entitled to Medicare).

CMS News #3: CMS to Host BCRC Recovery Process Webinar

On Wednesday, December 9, 2020 at 1:00 PM ET, CMS will be hosting a webinar focused on the Medicare Secondary Payer (MSP) recovery process when a Medicare beneficiary receives a settlement, judgment, award, or other payment. In other words, following its September webinar featuring the CRC, CMS is now highlighting the work of its Benefits Coordination and Recovery Center (BCRC). The announcement can be found here.

Per the announcement:

The primary intended audience is attorneys who represent beneficiaries and other beneficiary representatives. The BCRC will present a refresher on the beneficiary recovery process, including what functions can be facilitated using the Medicare Secondary Payer Recovery Portal (MSPRP). Such functions include submission of authorizations, requesting a Final Conditional Payment, and electronic payments. The webinar will also discuss alternative demand calculation options (Self-Calculated Conditional Payment Amount and Fixed Percentage Option), as well as other beneficiary recovery tips and best practices. The presentation will be followed by a question and answer session with participants.

We encourage anyone who is new to Medicare conditional payment recovery through the BCRC or would like, as CMS indicates, a refresher, to attend the webinar.

If you have any questions regarding these announcements, please contact Tower’s chief compliance officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.