BCRC Archives - Tower MSA

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.

$750 Medicare Conditional Payment Recovery Threshold Remains for 2021

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

Enhancements to MSPRP Improve Conditional Payment Processes

July 27, 2018

Since its introduction six years ago, the Medicare Secondary Payer Recovery Portal (MSPRP) has increasingly become more reliable and useful in communicating to and receiving information from the Medicare conditional payment recovery contractors (BCRC and CRC). Earlier this month, a revised version of the MSPRP User Guide was released (Version 4.2) and provided for further enhancements to the portal:

To reduce the number of calls received by the BCRC regarding the status of case correspondence, a new read-only Letter Activity tab has been added to the Case Information page, which displays correspondence that has been received or letters that have been sent related to a Benefits Coordination & Recovery Center (BCRC) or Commercial Repayment Center (CRC) case (Section 13.1.1).
To make MSPRP more consistent so that both insurers and beneficiaries (and their representatives) can request electronic letters, the MSPRP now allows insurers, recovery agents on the Tax Identification Number (TIN) reference file, and insurer representatives with a verified Recovery Agent Authorization, who also log in using multi-factor authentication, to request electronic conditional payment letters (eCPLs) for BCRC and CRC insurer-debtor cases (Sections 13.1.5 and 14.5.4). Note: eCPLs may also be requested on cases that are in bankruptcy.
To help Account Managers (AMs) determine which currently active designees should be deleted because of long inactivity on an account, a Last Login Date column has been added to the Designee Listing page (Section 8.3.2).
In cases where Part A, non-inpatient, claims do not have a HCPCS or DRG code associated with them, the Primary Diagnosis Code will appear on the Payment Summary Form (PSF), in bold, under the DX Codes column, along with an explanatory footnote. When the Primary Diagnosis Code is bolded, the HCPCS/DRG column will be blank (Table 13-8).

Practical Implications

Tower MSA staff often spend hours on the phone with the CRC and BCRC to ensure correspondence, such as an authorization, was received and that a matter is progressing to completion. The addition of a Letter Activity tab confirming correspondence has been received and acted upon is a significant benefit as long as the recovery contractors properly update it with the most current documentation received.

Additionally, the ability for an insurer or Tower MSA, on behalf of an insurer, to request an electronic conditional payment letter (eCPL) provides for a more expeditious turnaround time in obtaining this letter which is otherwise sent through the mail. Previously, eCPLs were only available to Medicare beneficiaries.

Update on New Commercial Repayment Center

Since the transition from CGI Federal to Performant Financial as the CRC contractor in February 2018, Tower MSA has encountered a reasonably quick turnaround time (Less than 30 days) in receiving Medicare conditional payment information. Interestingly, in the first few months following the contractor transition the CRC had been issuing Conditional Payment Letters (CPLs), rather than the Conditional Payment Notices (CPNs) (The difference being that a CPL does not have a 30 day time-frame to dispute conditional payments, nor is it followed by a Demand Letter). However, we are now seeing the CRC again issuing CPNs followed by Demand Letters.

While obtaining an itemization of Medicare conditional payments has been a smooth process with the new contractor, the same cannot be said for disputes and appeals of those conditional payments. Our understanding is the new contractor inherited a backlog of these disputes and appeals and has been working through them which has added to the time needed to process new disputes and appeals (Hence the likely reason CPLs were issued rather than CPNs in the first few months of the new contractor). Some disputes and appeals are pending for more than 60 days. Additionally, there have been systematic issues at the CRC resulting in lost disputes/appeals, demand letters issued while disputes are pending and matters prematurely being referred to the Treasury Department for collection activities.

Tower MSA has been advised by Performant that it is continuing to reduce the backlog of dispute and appeal submissions while also addressing the systematic problems. We are optimistic the portal enhancements and Performant acting to reduce the backlog and the systematic challenges will increase the efficiency of the conditional payment process over time. Tower MSA will continue to monitor these processes and when warranted reach out to the CRC to request corrective action be taken.

Enhanced Portal Functionality for Final Conditional Payment Process

November 10, 2015

In its ‘What’s New’ section, CMS announced on November 9, 2015 that as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final Conditional Payment (CP) process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.

When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP. Once calculated, this amount will remain the Final Conditional Payment Amount as long as:

The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.

How the NGHP recovery process works today

To understand the value of this announcement to simplify the final demand process, we need to revisit the recent changes in NGHP recovery and the new role of the Commercial Repayment Center (CRC).

Effective October 5, 2015, the CRC assumed responsibility for pursuing recovery directly from the applicable plan. Any recoveries initiated by the Benefits Coordination & Recovery Center (BCRC) prior to the October 2015 transition will continue to be the responsibility of the BCRC. The typical recovery case, where Medicare is pursuing recovery directly from the applicable plan, now involves the following steps:

1. Medicare is notified that the applicable plan has primary responsibility

Medicare may learn of other insurance through a Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 report or beneficiary self-report. If Medicare is notified that the applicable plan is primary to Medicare, Medicare records are updated with this information.

2. CRC searches Medicare records for claims paid by Medicare

The CRC begins identifying claims that Medicare has paid that are related to the case, based upon details about the type of incident, illness, or injury alleged. The claims search will include claims from the date of incident to the current date. If a termination date for Ongoing Responsibility for Medicals (ORM) has already been reported, the CRC will collect claims through and including the termination date.

3. CRC issues Conditional Payment Notice (CPN) to the applicable plan

The CPN provides conditional payment information. It advises the applicable plan that certain actions must be taken within 30 days of the date on the CPN or the CRC will automatically issue a demand letter. This notice includes a claims listing of all items and services that Medicare has paid that are related to the case. It also explains how to dispute any items and services that are not related to the case. A courtesy copy of the CPN is sent to the beneficiary and beneficiary’s attorney or other representative. The applicable plan’s recovery agent will also receive a copy of the CPN if the recovery agent’s information was submitted on the applicable plan’s MMSEA Section 111 report or the applicable plan has otherwise appointed a recovery agent by submitting a written authorization to the CRC.

Note: If a beneficiary or his or her attorney or other representative reports a no-fault insurance or workers’ compensation situation before the applicable plan submits a Section 111 report, the applicable plan will receive a Conditional Payment Letter (CPL). The CPL provides the same information as a CPN, but there is no specified response timeframe. When this occurs, the applicable plan is encouraged to respond to the CPL to notify the CRC if it does not have ORM and will not be reporting ORM through Section 111 reporting or if the applicable plan would like to dispute relatedness.

4. Applicable plan submits a dispute

The applicable plan has 30 days to challenge the claims included in the CPN. The applicable plan may contact the CRC or use the Medicare Secondary Payer Recovery Portal (MSPRP) to respond to the CPN.

5. CRC issues recovery demand letter advising plan of monies owed to Medicare

The demand letter advises the applicable plan of the amount of money owed to the Medicare program and requests reimbursement within 60 days of the date of the letter. A courtesy copy of the demand letter is sent to the applicable plan’s recovery agent, the beneficiary and the beneficiary’s attorney or other representative. The demand letter includes the following:

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
The total demand amount (amount of money owed) and information on administrative appeal rights.

If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

An applicable plan has 120 days from the date the applicable plan receives the demand letter to file an appeal. Receipt is presumed to be within 5 calendar days absent evidence to the contrary.

7. Applicable plan submits payment

If the CRC receives payment in full, it will issue a letter stating that the specified debt has been resolved. The letter will also note that new cases may be created if the applicable plan maintains ORM or the CRC receives information on additional items or services paid by Medicare during the period of ORM.

Facilitating timely and more accurate final demands

Because the CRC retains the right to create new cases as long as the applicable plan maintains ORM, timely notification of a final settlement is extremely critical to terminate the recovery efforts of the CRC. We applaud the addition of CP process functionality to the MSPRP as a segue to real time information and data exchange, and a more predictable outcome.

With more timely submissions and a published timeline for the final demand, this new extension of the SMART Act will facilitate better accuracy, a better path to closure and fewer last minute surprises…. all good things for those who represent the settlement interests workers’ compensation and liability carriers.