Conditional Payments Archives

Why Case Studies Matter: Real-World Proof of MSA Savings

October 7, 2025

Image of Tower MSA Partners Why Case Studies Matter series: Blog 1 Real-World Proof of MSA Cost Savings.

While Medicare Set-Asides (MSAs) are essential for compliance in certain workers’ compensation settlements, they can also lead to inflated costs if not carefully managed. Without proper oversight, unnecessary treatments, duplicate services, or overly conservative assumptions can cause MSA totals to rise dramatically. These inflated amounts not only delay settlements but also tie up resources that could be better used elsewhere.

At Tower MSA Partners, we help insurers, self-insured employers, and third-party administrators (TPAs) navigate this complex process with precision and cost control, ensuring settlements are compliant, efficient, and fair.

This kickoff blog launches a 12-month series of real-world case studies demonstrating how proactive strategies, clinical expertise, and deep regulatory knowledge deliver measurable savings and smoother claim resolutions.

Common MSA Challenges

For many claims professionals, MSAs can feel like a “black box.” The process often seems like paperwork sent off to CMS, followed by a waiting game for approval. This lack of transparency can lead to missed opportunities for cost savings and compliance improvements.

Here are a few recurring challenges we see: – Unnecessary treatments or duplicate costs included in MSA submissions – – inconsistent and contradictory treatment patterns – Lack of early intervention to address treatment plans before they escalate – Missed opportunities to optimize claims for both cost control and compliance

These issues affect everyone involved—from injured workers to payers. Through detailed case studies, this series will show how a strategic, proactive approach prevents these challenges and leads to better settlement outcomes.

Real Savings, Real Impact

The strength of this series is in real numbers and real results. In the coming months, we’ll highlight outcomes such as: – $774,000 saved by identifying and resolving issues before MSA submission – $1 million saved through a physician peer review that corrected unnecessary treatment recommendations – $98,000 saved with a second-opinion MSA review before finalizing settlement

These results represent actual cases handled by Tower MSA Partners. They demonstrate how compliance and cost containment can work together to protect Medicare’s interests while avoiding overfunding.

Why Case Studies Matter

Every claim is unique, yet the challenges surrounding MSAs are surprisingly consistent across the industry. Factors like rising medical costs, evolving CMS guidelines, and the push to close claims quickly create a complex balancing act.

Through these case studies, Tower MSA Partners aims to: – Improve the quality and defensibility of MSA submissions – Speed up settlements by eliminating preventable delays – Lower claim costs without compromising care – Provide clarity and confidence for claims professionals handling complex cases

When payers understand why certain costs are included and how they can be managed, they make smarter, more informed decisions that benefit their organization and the injured workers they serve.

What’s Ahead in the Series

Each month, we’ll release new content focusing on a specific area of MSA management, including: – Early Intervention Strategies – Preventing inflated costs before an MSA is created – Physician Peer Review – Validating treatment plans and prescriptions – Compliance Best Practices – Reducing the risk of CMS penalties and rejections – Ongoing Claim Management – Preventing cost creep over time – Legacy Claim Resolution – Closing backlogged claims to free reserves and improve efficiency – Case Optimization and Review – Streamlining processes to improve accuracy and outcomes

The series will conclude with a Top 10 Lessons Learned wrap-up blog summarizing a year’s worth of data and insights for claims professionals and legal teams.

The Takeaway

MSAs don’t have to be overwhelming or overly expensive. With the right approach, organizations can achieve compliance, control costs, and resolve claims efficiently. This series will provide real-world proof of how Tower MSA Partners helps clients reach these goals, step by step.

Stay tuned for our first in-depth case study, where we’ll explore how early intervention prevented nearly $800,000 in unnecessary costs and paved the way for a smooth, compliant settlement.

Frequently Asked Questions

What causes Medicare Set-Asides to become inflated?
Inflated MSAs often come from unnecessary treatments, duplicate services, outdated prescriptions, or conservative medical assumptions that were never updated.

Why do MSA case studies matter?
They show real savings and real outcomes so payers can understand how proactive MSA strategies improve accuracy, compliance, and cost control.

What are the most common challenges in MSA preparation?
Unnecessary care, inconsistent documentation, lack of early intervention, and missed opportunities to correct treatment plans.

How does Tower MSA Partners reduce MSA costs?
Through early clinical review, pharmacy analysis, physician communication, and regulatory expertise that remove unnecessary or inaccurate costs.

Who benefits from proactive MSA management?
Claims adjusters, TPAs, self-insured employers, risk managers, and injured workers all benefit through faster, cleaner, and more cost-effective settlements.

How much can proactive MSA strategies save?
Savings vary, but real cases show reductions such as $774,000 saved before MSA submission and $1 million saved via physician peer review.

Does improving MSA accuracy slow down settlements?
No. Addressing medical and documentation issues early creates smoother CMS approvals and eliminates preventable delays.

What topics will this 12-month case study series cover?
Early intervention, physician peer review, compliance best practices, legacy claim resolution, and prevention of medical cost creep.

How does this series help claims professionals?
It provides transparent examples, clearer processes, and actionable steps for improving accuracy, compliance, and settlement outcomes.

A Claims Professional’s Guide to Common MSP Acronyms and Abbreviations

January 19, 2023

Picture of scrabble tiles that could be put together to create MSP ACRONYMs

People in the MSP compliance business rattle off acronyms and abbreviations, such as AWP, MMSEA, and TPOC like it’s second nature. People immersed in Section 111 reporting and Medicare Set-Asides understand the abbreviations, but most people listening to us do not. So, here’s a quick cheat-sheet (or handy guide) to frequently used acronyms and their meanings:

Common MSP Acronyms and Abbreviations

AWP – Average wholesale price: The AWP is a Red Book pricing reference for prescription drugs. The lowest AWP is used to calculate Medicare Part D drugs in a Workers’ Compensation Medicare Set-Aside (WCMSA).

BCRC – Benefits Coordination & Recovery Center: This contractor to the Centers for Medicare and Medicaid Services consolidates the activities that support the collection, management, and reporting of other primary insurance coverage for Medicare beneficiaries. In short, it manages the MMSEA Section 111 reporting program and pursues conditional payment recovery when the claimant Medicare beneficiary is the debtor.

CMS – Centers for Medicare and Medicaid Services: The federal government agency oversees the Medicare program. CMS’s Division of MSP Program Operations directly manages CMS’s Medicare Secondary Payer (MSP) enforcement programs.

COB – Coordination of Benefits: The coordination of benefits (COB) program aims to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken payment of Medicare benefits.

CRC – Commercial Repayment Center: This CMS contractor pursues conditional payment recovery when the self-insured entity or the insurer is the identified debtor.

CWF – Common Working File: CMS uses this tool to maintain national Medicare records for individual beneficiaries enrolled in the Medicare program. For example, a funded CMS-approved workers’ compensation Medicare Set-Aside (WCMSA) will trigger a marker in the CWF, so Medicare will not pay for care covered by the WCMSA.

LMSA – Liability Medicare Set-Aside: General term for an MSA in a liability case settlement.

MBI – Medicare Beneficiary Identifier: The Medicare Beneficiary Identifier (MBI) is the identification number replaced SSN-based health insurance claim numbers (HICNs) on all Medicare transactions, such as Medicare cards, billing, claim submissions and appeals.

MIR – Mandatory Insurer Reporting: Another term for MMSEA Section 111 reporting.

MMSEA – Medicare, Medicaid, SCHIP Extension Act of 2007: Section 111 of this act added mandatory reporting requirements regarding Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards, or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation, collectively referred to as Non-Group Health Plan (NGHP) or NGHP insurance.

MSA – Medicare Set-Aside: An account used to pay for injury-related and Medicare-covered medical services and prescription medications. It is a portion of a settlement that is reserved or “set-aside” for this purpose.

MSP – Medicare Secondary Payer: This is the term generally used when the Medicare program does not have primary payment responsibility, that is when another entity, such as workers’ compensation or liability insurance or a group health plan, is responsible for paying before Medicare.

MSPRP – Medicare Secondary Payer Recovery Portal: A web-based tool designed to assist in the resolution of liability insurance, no-fault insurance, and workers’ compensation Medicare recovery cases.

NGHP – Non-Group Health Plan: Typically used in reference to Section 111 reporting, NGHP includes liability insurance (including self-insurance), no-fault insurance, and workers’ compensation.

ORM – Ongoing Responsibility for Medicals: This refers to the Responsible Reporting Entity (RRE) paying for the injured party/Medicare beneficiary’s ongoing medical treatment associated with the claim.

RO – Regional Office: A CMS RO is assigned to each WCMSA case (based on the claimant’s state of residence); that RO makes the final determination of the appropriate funding level for the WCMSA.

RRE: Responsible Reporting Entity: The applicable plan, namely the NGHP, responsible for Section 111 reporting to CMS.

SSDI – Social Security Disability Insurance: Pays monthly benefits to workers who can no longer work due to a significant illness or impairment that is expected to last at least a year or result in death within a year.

SSN – Social Security Number: A numerical identifier assigned to U.S. citizens and other residents to track income and determine benefits.

TPOC – Total Payment Obligation to the Claimant: For Section 111 reporting purposes, CMS uses the term TPOC to refer to the dollar amount of the total payment obligation to, or on behalf of, the injured party in connection with the settlement, judgment, award, or other payment in addition to/apart from ORM.

WCMSA – Workers’ Compensation Medicare Set-Aside: This is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease.

WCMSAP – Workers’ Compensation Medicare Set-Aside Portal: The WCMSAP may be used to submit and view WCMSA proposals, to communicate about the review approval process, and to submit re-review requests. Users can also view the status and balance of an established WCMSA and submit annual attestations and detailed transaction records.

WCRC – Workers Compensation Review Contractor: This CMS contractor reviews all submitted WCMSAs and advises the CMS Regional Office whether the proposed WCMSA is sufficient, or a higher or lower amount is recommended.

Tower Releases White Paper on Future Medicals in Liability Settlements

December 13, 2022

woman sitting in a dr waiting room to discuss her liability case

This past October, the Centers for Medicare and Medicaid Services (CMS) withdrew its proposed rule on future medicals in liability settlements from review by the White House Office of Information and Regulatory Affairs (OIRA). (See CMS Withdraws Proposed Rule on Future Medicals in Liability Settlements).

Right now, we don’t know if a proposed rule around Liability Medicare Set-Asides (LMSAs) will be reworked and resubmitted to OIRA for consideration soon or whether CMS is closing out regulations around liability settlements and future medicals for the foreseeable future.

Given the lack of guidance from CMS, we thought this was an opportune time to update our white paper, Navigating through the Fog: Medicare, Future Medicals & Liability Settlements. Authored by Tower’s Chief Compliance Officer Dan Anders, the paper explores CMS authority to regulate future medicals and provides guidance to the liability practitioner as to how to address future medicals at the time of settlement.

Post-Settlement Care, Cost and Compliance Through Professional Administration

December 6, 2022

Picture of Medicare billing statement for Section 111 WCMSA reporting.

While workers’ comp payers invest considerable resources to manage and settle claims, they don’t always prepare Medicare-eligible injured workers for life after settlement. These patients have usually been in the workers’ comp system for several years. And the system has paid for their injury’s treatment and medication, and in some cases, coordinated their care.

When their claim closes, all that comes to an end. Injured workers are on their own to navigate the healthcare system and handle the bills. They need to pay for doctors’ visits and medication from their Medicare Set-Asides (MSAs). They also need to make sure Medicare doesn’t have to pay for their injury-related care. Post-settlement compliance responsibilities can be overwhelming.

Tower’s recent Premier Webinar: Care, Cost & Compliance Through Professional Administration featured Nicole Chappelle who has nearly 30 years’ experience in all aspects of claims management — before and after settlement. Now Vice President of Settlement Solutions for Tower’s partner Ametros, Nicole joined our Chief Compliance Officer Dan Anders for what could be our liveliest webinar yet.

Here are some takeaways:

Injured workers who are also Medicare beneficiaries can self-administer their MSA or use professional administration.
The Centers for Medicare and Medicaid Services (CMS) highly recommends professional administration for beneficiaries who take opioids and other frequently abused controlled substances.
Professional administration is available for MSAs that are CMS-approved and for those that are not submitted for CMS approval.
Payers typically cover Ametros’ one-time professional administration fee of $1,000.

Although CMS allows beneficiaries to self-administer an MSA, it strongly recommends they consider professional administration. So do we.

First, MSA funds can only be used to pay for Medicare-covered medical treatment and prescription drugs related to the claim. Learning what Medicare does and doesn’t cover is challenging at best. It’s even more confusing for an injured worker whose workers’ comp program paid for items that Medicare does not cover, such as a sophisticated power wheelchair, home healthcare, and off-label use of certain medications. Will the typical, older injured worker understand this?

Additionally, MSA funds must be kept in an interest-bearing checking or savings account and used only for the aforementioned Medicare-covered care related to the claim. Even the interest needs to be used for this purpose.

The administrator has to maintain itemized medical and pharmacy receipts, bank statements, and other records for each transaction from the MSA account. An attestation of these expenditures needs to be submitted to the Benefits Coordination & Recovery Center (BCRC) every year.

If the MSA is funded with an annuity and funds run out in any given year, the administrator must report the temporary exhaustion of funds to the BCRC. Should funds be permanently exhausted, the administrator needs to send the BCRC a final attestation letter confirming the situation.

If MSA funds remain when the beneficiary dies, the executor or administrator is to notify the BCRC and pay for outstanding (related) medical bills from the fund. But would an executor know to do this?

Some things are best left to professionals.

If you’d like to see the whole webinar, please contact Dan Anders at daniel.anders@towermsa.com for the link and slides. He’s happy to connect you with Nicole Chappelle, too. And, as always, if you have any questions about MSAs, post-settlement compliance, or other Medicare Secondary compliance issues, get in touch with Dan.

Build a Better Tower: Partnerships Speed Settlements of Workers’ Comp Claims with Medicare Set-Asides (towermsa.com)

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.

$750 Medicare Conditional Payment Recovery Threshold Remains for 2021

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

April 1st Brings Electronic Payment Option to MSPRP

March 15, 2019

Tower MSA Partners covers CMS new guide on Medicare conditional payment appeals and the upcoming Section 111 reporting webinar.

In a March 13, 2019 webinar, CMS provided a high-level overview of the electronic payment option to be added to the Medicare Secondary Payer Recovery Portal (MSPRP) effective April 1, 2019. Below are the step-by-step instructions for using this E-Payment service:

Login to the MSPRP and select the Case ID link from the Cases table for the case in which you would like to make a payment.

On the Payment Information tab select the Make a Payment button on the lower left-hand corner.

Then, on the Make a Payment page you will find the Remaining Principal Amount, Remaining Interest Amount and Total Remaining Balance Amount. In the Amount Field the amount to be paid is entered, either a partial or full amount, and in the Account Holder Name field the account holder name as it appears on the account under which payment will be made. Click Continue.

Once you click Continue you will be taken to Pay.gov in a new internet browser window (Pay.gov is a secure, online payment system run by the U.S. Department of Treasury). On this screen Pay.gov requires you to choose one of the following payment methods: Direct payment from checking or savings account, debit card or PayPal. Credit card transactions are not allowed (We assume this is to avoid the credit card fees which would otherwise limit the government’s recovery).

Once the payment method is chosen you will be taken to an Enter Payment Information screen and then a Review and Submit Payment screen (Maximum amount for a debit card is $24,999.99 and for PayPal it is $10,000). Once payment is submitted the next screen will indicate either the payment is in process or declined with a confirmation number, Case ID and Debtor Name.

After the payment process has been completed on Pay.gov you will then be taken back to the Case Information page in the MSPRP. Here you can view a tab with the electronic payment history.

CMS advised that payment processing time is 1 to 3 days on average and the statement will indicate a payment to “HMSCMS.” Importantly, CMS advised that for the purpose of interest calculations the date the electronic payment is made will be the receipt date for payment, not when the payment is processed.

If in the process of using Pay.gov any problems are experienced Pay.gov customer support can be contacted at 800-624-1373 (Select Option #2) or pay.gov.clev@clev.frb.org.

Notably, if following an electronic payment, Medicare determines that a refund of all or part of the payment is required, the refund will not be credited back to the form of payment, i.e. debit card, used to make the electronic payment. Instead, a physical check will be issued to the address on file.

Practical Implications

The addition of the electronic payment option to the MSPRP is a welcome upgrade to not only the portal, but the process of resolving Medicare conditional payments. Importantly, electronic payment of a Medicare conditional payment demand requires you to have access to the MSPRP and have an authorization on file with the recovery contractor allowing for access to the demand on the particular case (Medicare beneficiaries do not need an authorization on file but must access the MSPRP through MyMedicare.gov). If you do not have such access or choose not to make an electronic payment, then the traditional method of mailing a check to either the CRC or BCRC is still available.

CMS advised that the slides from the webinar will be available on the CMS website next week. If you have any questions, please contact Dan Anders at (888) 331-4941 or daniel.anders@towermsa.com.

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.

Proposed PAID Act Intends to ID Medicare Part C, Part D and Medicaid Enrollees for Insurers

June 1, 2018

On 5/18/2018, the Provide Accurate Information Directly Act (or the proposed PAID Act) was introduced in Congress for the purpose of allowing settling parties an easy method to identify if a claimant is enrolled in a Part C or D plan or Medicaid. The bill, H.R. 5881, sponsored by U.S. Rep. Gus Bilirakis R-Fla and U.S. Rep. Ron Kind, D-Wisc, requires the Centers for Medicare and Medicaid Services (CMS) to share information on not only whether a claimant is a Medicare beneficiary, but also whether the claimant is enrolled in a Part C Medicare Advantage (MA) Plan, Part D Prescription Drug Plan or Medicaid. It also requires CMS to provide the identity of the MA or Part D Plan or state Medicaid program in which the claimant is or was enrolled.

The catalyst for this legislation comes from stepped up efforts by these various plans and programs, especially by MA Plans, to seek reimbursement from settling parties. MA Plans have largely prevailed against insurance carriers in seeking reimbursement under the Medicare Secondary Payer Act which has led to a heightened awareness of the potential for such claims and the need to identify claimants enrolled in such plans and programs prior to settlement.

While liability and no-fault carriers and workers’ compensation plans are now on notice of the potential for such reimbursement claims, there presently exists no universal method to identify a claimant’s enrollment status, short of asking the claimant. Accordingly, the bill provides a solution by requiring CMS to share such enrollment information.

A review of the proposed PAID act shows the enrollment information would be shared through the Section 111 Mandatory Insurer Reporting query process. In short, along with identification of whether a claimant is a Medicare beneficiary, the query response would also provide whether the claimant is or has been enrolled in a MA or Part D Plan or a state Medicaid program for the past three years and the name of the plan or program. The insurance carrier or self-insured entity would then be able to readily contact the Part C or D plan or Medicaid program to resolve any claim for reimbursement.

The bill was referred to the Committee on Ways and Means and the Committee on Energy and Commerce for further action. Tower MSA Partners will provide updates on the legislation when warranted.

CRC Contractor Change Brings New Team to Medicare Conditional Payment Recovery Efforts

January 21, 2018

On Thursday, January 18, 2018, the Centers for Medicare and Medicaid Services (CMS) held a webinar to introduce the new Commercial Repayment Center (CRC) contractor, Performant Recovery, and Performant’s management team. This transition to a new contractor is important to insurers and employers as the CRC is responsible for the recovery of Medicare conditional payments against these entities stemming from liability, workers’ compensation and no-fault claims where ongoing responsibility for medicals has been accepted.

Ted Doyle, the Performant MSP CRC Project Director, emphasized in his introductory remarks and throughout the presentation that their main goal is to make the transition seamless for all those who engage with the CRC. His message to stakeholders is CMS’s recovery processes and timeframes remain the same, it is only the entity handling those processes that is changing.

Besides Mr. Doyle, other webinar participants were John Albert, the Director of the CMS Division of Medicare Benefit Coordination and Laura Martinez, the MSP CRC NGHP Recovery Manager for Performant.

Key contractor transition information provided during the webinar was as follows:

The current CRC contractor, CGI Federal, will cease operations effective Friday, February 9, 2018.
Performant Recovery will commence CRC operations effective Monday, February 12, 2018.
Transition cutover, or what CMS calls “Dark Days,” will occur on February 8 and 9. During this period while CGI Federal will continue to answer telephone calls and the Medicare Secondary Payer Recovery Portal (MSPRP) will be available, the information will be limited to what was available at close of business on February 7. Also, uploading documents through the MSPRP will not be available.
Performant will go live as of 8am EST on February 12 at which point the MSPRP will once again be fully available as well as the call center. Correspondence received during the Dark Days or prior to the transition will be transferred to Performant for handling.

In regard to what will remain the same post-transition:

All current cases initiated by CGI will be transitioned to Performant.
Case information, copies of communication, correspondence and contact information, including letters of authority, will be fully accessible to Performant such that there should be no reason for stakeholders to resend correspondence or other information that was previously provided to CGI.
There will be no changes to CMS established recovery processes or timeframes applicable to MSP recovery.
The CRC Call Center will continue the same hours: 8am – 8pm EST
The CRC Call Center phone number will remain the same: (855) 798-2627
All Benefits Coordination and Recovery Center (BCRC) processes remain the same, including Section 111 Mandatory Insurer Reporting.

As for what is changing post-transition:

Effective 2/12/2018* the CRC has a new address:Medicare Commercial Repayment Center – NGHP ORM
P.O. Box 269003
Oklahoma City, OK 73216

*Any correspondence received prior to 2/12/2018 will be held and then processed starting on that date.
Effective 2/12/2018 the CRC fax number is (844) 315-7627.

As with any transition, some bumps are to be expected. We are hopeful these will be short-term and that the transition will not only be seamless, but that Performant improves the customer service aspect of the Medicare conditional payment recovery process. CMS and Performant engaging with Tower MSA and other stakeholders through this webinar is a good first step at building a collaborative relationship with those impacted by the CRC’s recovery efforts.

It was indicated a copy of the presentation slides will be made available on the downloads section of the CMS Coordination of Benefits and Recovery website next week.

If you have any questions regarding the CRC contractor transition, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941.

Daniel Anders, Esq., MSCC

Daniel M. Anders is the Chief Compliance Officer for Tower MSA Partners where he oversees the Medicare Secondary Payer (MSP) compliance program. Dan is an attorney licensed to practice in the State of Illinois and the United States District Court for the Northern District of Illinois.