Conditional Payments Archives

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

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

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.

CMS to Host Webinar on Transition to New CRC Contractor

January 9, 2018

On Thursday, January 18, 2018, at 1:00 PM ET, the Centers for Medicare and Medicaid Services (CMS) will host a webinar for the purpose of introducing the new Commercial Repayment Center (CRC) contractor to Non-Group Health Plans.

The CRC is responsible for recovery of Medicare conditional payments from liability insurers (including self-insured entities), no-fault insurers and workers compensation entities where such entities are the identified debtor by Medicare. It was announced last October that the new CRC contract had been awarded to Performant Financial Corporation (See Tower MSA article: New Commercial Repayment Center Contractor on the Horizon). The transition to the new contractor is to occur on February 8, 2018.

According to the January 5, 2018 CMS Notice, the webinar will consist of opening remarks and a presentation by CMS followed by a Q & A session. We encourage anyone who has regular contact with the CRC to register and attend the presentation (A link to register is located in the CMS Notice). If you are unable to attend, Tower MSA will provide a summary of relevant information on our MSP Compliance Blog following the presentation.

As CMS contractor changes are often fraught with a subsequent period of longer turnaround times and inconsistent communication with contractor representatives, we hope this transition proves an exception to past experiences. This introductory webinar appears to be a useful first step.

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

Updated Section 111 User Guide Provides for Transition to MBIs, ORM Termination Defined

January 3, 2018

Pursuant to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, CMS is required to transition all Medicare beneficiaries from the Social Security Number based Health Insurance Claim Numbers (HICNs) to a new identification number called a Medicare Beneficiary Identifier (MBI). The primary purpose of this initiative is to reduce identify theft associated with use of Social Security Numbers in HICNs.

Accordingly, starting in April 2018 CMS will begin to mail new cards with the new Medicare numbers to Medicare beneficiaries. The goal is to issue all new cards by April 2019. For medical providers, there will be a transition period from 4/1/2018 through 12/31/2019 in which either the HICN or MBI will be accepted for processing of payments by Medicare.

Minimal Impact on Section 111 Reporting

Unlike medical providers which must exclusively use the MBI by 1/1/2020, as explained in the updated Section 111 NGHP User Guide, CMS has exempted its Medicare Secondary Payer Reporting processes from exclusive use of the MBI. Consequently, we can continue to report to CMS using a Social Security Number, a HICN or an MBI. In announcing this policy, CMS indicates it has renamed fields labeled “HICN” to “Medicare ID.”

While allowing for continued reporting of HICNs in its Section 111 reporting processes, CMS states that if an MBI has been issued to the claimant, it will return the MBI in the Section 111 response files. We expect then that while not requiring submission of MBIs, CMS nonetheless expects a natural transition to their use for MSP matters over time.

Medicare Conditional Payment Recovery Correspondence to Include Either HICN or MBI

As part of this update, CMS states that its recovery contractors, the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC), will use either an HICN or MBI in its correspondence based upon the most recent information provided by the Responsible Reporting Entity (RRE) when creating or updating the MSP record. Again, we expect a natural transition from use of HICNs to MBIs in correspondence from the recovery contractors over the next few years.

The Tower MSP Automation Suite is fully capable of accepting SSNs, HICNs or MBIs for purposes of Section 111 Mandatory Insurer Reporting.

ORM Termination Defined

In addition to updating its User Guide to address the transition to MBIs, CMS also added language to its Section 111 “Policy Guidance” User Guide specifically defining under what circumstances Ongoing Responsibility for Medical (ORM) may be terminated. The revised Section 6.3.2 states as follows:

6.3.2 ORM Termination

When ORM ends, the RRE should report the date that ORM terminated and should NOT delete the record. Please note that a TPOC amount is not required to report an ORM termination date. An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:

Where there is no practical likelihood of associated future medical treatment, an RREs may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;

Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.

While now formalized, this ORM termination guidance had previously been provided by CMS, either in other sections of the User Guide or in guidance provided outside the guide, such as through CMS Townhall calls.

Notably, advocacy efforts have been made with CMS to request an expansion of the ORM termination criteria. Such expansion would, for example, provide for ORM termination if no medical has been paid on a claim over a certain number of years. The benefit of allowing for a greater number of claims to terminate ORM would be less of an administrative burden for employers and carriers and a reduction in denials of payment by Medicare for charges completely unrelated to reported claims.

Unfortunately, CMS has thus far been unresponsive to expanding its definition of ORM termination, choosing instead to work out improper denial of payments and unwarranted conditional payment recovery efforts on the back-end rather than addressing the quality of the data reported to CMS on the front-end.

The Updated Section 111 User Guide, Version 5.3, may be found here.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding the updated guide.

Don’t Plan to Fail: Best Practices for Addressing Medicare Advantage Plan Reimbursement

October 25, 2017

Benjamin Franklin must have been contemplating Medicare Advantage Plan reimbursement when he uttered one of his famous lines: “If you fail to plan, you are planning to fail.” Over the past few years Medicare Advantage plans have increasingly been seeking reimbursement for payments made stemming from workers’ compensation, liability and no-fault claims, otherwise known in Medicare circles as Non-Group Health Plans (NGHPs). Despite these increasing efforts, many NGHPs have not planned how they should respond to such reimbursement claims.

With the goal of working with our clients to educate and assist with proper planning, earlier this month, Tower MSA was privileged to have Brian Bargender, Subrogation & Other Payer Liability Business Consultant for Humana, participate in a webinar to discuss reimbursement rights of Medicare Advantage plans, and best practices for investigating and responding to reimbursement claims. For those who were unable to attend, or would like a refresher, we are pleased to provide below a summary of Mr. Bargender’s presentation along with some final thoughts and takeaways.

Medicare Advantage Plan Background

Part C Medicare Advantage plans (MA plans) are alternative delivery mechanisms for traditional Medicare benefits (Parts A and B) provided by private companies under contract with CMS. Medicare beneficiaries have the option of choosing one of these Medicare Advantage plans during annual or special enrollments periods. The three largest MA plan sponsors (representing almost half of the available plans) are UnitedHealthcare, Humana and Aetna. As of 2017, one-third of Medicare beneficiaries are enrolled in MA plans.

Medicare Advantage Plan Recovery Rights

Pursuant to CMS direction, MA plans must enforce the Medicare Secondary Payer Act (MSP) and will be audited by CMS for compliance with the Act. Consequently, these plans are obligated to coordinate benefits such that MA Plan coverage is denied when a primary payer is covering treatment and when the MA plan pays, but later learns of primary payer responsibility, seek reimbursement for payments made relating to the particular workers’ compensation, liability or no-fault claim.

MA plans right to reimbursement, including double damages, from NGHPs under the MSP Act has been acknowledged in at least two significant federal appellate court decisions:

In re: Avandia, 685 F.3d 353 (3d Cir. 2012)
Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016)

Medicare Advantage Plan MSP Enforcement Challenges

Despite CMS’s direction to MA plans regarding enforcement of the MSP Act, including coordination of benefits, the data available to the MA plans to perform this task is inconsistent and error prone. Consequently, MA plans have taken one of three approaches to MSP enforcement:

Inactive: Minimal effort
Reactive: Relying upon member and medical provider reporting of primary plans
Proactive: Claim screening and investigation

As Mr. Bargender explained, Humana is taking the proactive approach. Nonetheless, the challenges faced by Humana in identifying coordination of benefits situations has proven difficult as a result of gaps in medical provider and Medicare beneficiary self-reporting and data provided by CMS which is “too little, too late, often wrong.” Additional challenges faced by MA plans are incomplete direction from CMS and non-cooperation of Medicare beneficiaries and plaintiff attorneys to MA plan reimbursement claims. As such, Humana utilizes a multi-faceted approach of member questionnaires, public records, such as accident reports and workers’ compensation claims, and non-public records, such as data relayed by CMS, to determine possible MSP coordination of benefits and reimbursement opportunities.

Best Practices for Non-Group Health Plans and MA Plan Reimbursement

Humana’s proactive approach then has the ultimate goal of reimbursement for charges related to the claimed injury. Mr. Bargender shared the following basic precautions to be taken by NGHPs:

Train front-line staff on MSP basics – including MA & Part D
Assume older & disabled claimants have some form of Medicare
Be proactive when told claimants don’t have original Medicare
Watch for other payer info in medical records
Watch for notices from other payers
No-fault and accepted work-comp claims
Pay treating providers directly for outstanding medical bills
Be suspicious of billing gaps (other payer?)

And when it comes to Liability and disputed or denied workers’ compensation claims:

Find out who paid for medicals

Providers rarely wait for settlements
CMS “no payment” letters aren’t the last word
Request benefit ID card(s)
Ask to see other payer “no payment” letters
Medicare/Medicaid dual beneficiaries? …assume Part D paid Rx

Address MSP repayment before agreeing to settlement

Determine amount before settlement is finalized
Don’t assume plaintiff will reimburse MA plan or unpaid providers
What does settlement indemnification language actually accomplish?

In terms of negotiating and resolving MA plan claims for reimbursement, Mr. Bargender offered as follows:

Most MA plans are open to working with primary payers

Focus on these:

Rationale for denying beneficiary’s underlying claim, not MA/Part D rights
Limits exhausted, treatment not allowed/capped, etc.
What’s related (was it in the demand or release?)
Errors in plan’s payment ledger
Extenuating circumstances

Not on these:

Reasonableness of amounts paid by MA
Claim filing time limits vs. MSP statute of limitations
Contract language” in the MA Evidence of Coverage document

Final Thoughts and Takeaways

In working with Mr. Bargender and the subrogation team at Humana, we have found them very helpful in promptly identifying specific reimbursement claim information where the claimant was enrolled in a Humana Medicare Advantage plan. Further, they are open to understanding the particular liability issues and bases for settlement, something not typically found with the Medicare conditional payment recovery contractors.

The primary takeaway from Mr. Bargender’s presentation is NGHPs must be proactive in identifying whether a Medicare eligible claimant is enrolled in a MA plan, and, if so, investigate whether the plan is seeking reimbursement for payments made related to the claim. As there exists no central database accessible to NGHPs in which to identify the MA plan a claimant is enrolled, the claims handler must be proactive in inquiring of the claimant whether they are enrolled in such a plan.

Tower MSA Partners will work with our clients to assist in identifying whether a claimant may be enrolled in a MA plan, identify the name of the plan and investigate whether such plan is seeking reimbursement stemming from the claim. We stand ready to assist you through general consultation on ensuring your MSP compliance program appropriately addresses MA plans or consultation on MA plan recovery* in a specific claim.

*While we did not delve into Part D Prescription Drug plans in this article, such plans arguably have similar reimbursement rights as Part C Medicare Advantage plans. NGHPs should also be aware of the potential for reimbursement claims from these plans.
Daniel Anders

New Commercial Repayment Center Contractor on the Horizon; WCRC Contract Protested

October 9, 2017

A recent press release from the Performant Financial Corporation announced it has been awarded the Commercial Repayment Center (CRC) contract by the Centers for Medicare and Medicaid Services (CMS). Barring a bid protest, we expect a transition to the new CRC contractor over the next few months (CGI Federal’s contract, the outgoing CRC contractor, appears to run through 1/8/2018).

CRC Responsibilities

The Commercial Repayment Center is responsible for identifying and recovering primary payments mistakenly made by the Medicare program when another entity had primary payment responsibility (otherwise known as conditional payments). While CGI Federal has had the responsibility for recovering from group health plans for several years, it has been recovering from non-group health plans, such as a liability insurer, no-fault insurer, or workers’ compensation entity, only since 10/1/2015.

As those of you who have had any dealing with the CRC know, communication with the CRC following that start date was often frustrating as a result of long turnaround times to receive conditional payment information and inconsistent and contradictory responses from CRC representatives. While communication with the CRC has definitely improved over time, CMS has nonetheless chosen not to renew their contract with CGI Federal. CMS’s reasons are unstated, but as we noted in a recent article, CMS Releases Annual Report on CRC Conditional Payment Recovery, conditional payment amounts recovered by the CRC on behalf of Medicare declined from 2015 to 2016, despite the expansion of CRC’s recovery efforts to non-group health plans.

Besides the CRC contract, Performant currently acts as a Recovery Audit Contractor (RAC) for Medicare’s fee-for-service program (Parts A and B). As a RAC, Performant identifies and corrects improper payments made to medical providers as a result of insufficient documentation to support the payment, payments made which do not meet CMS guidelines and payments made for services that are incorrectly coded.

Similar to the RAC contract, the CRC contract is paid on a contingency basis. Consequently, the CRC contractor has an incentive to recover as much as possible on behalf of CMS. Per the Performant press release, “at full scale, Performant anticipates staffing the program with over 250 dedicated employees operating out of Performant’s offices around the country.”

CMS contractor transitions (see below bid protest) usually do not go as smoothly as advertised, thus we will wait and see how effectively this new contractor takes on the role as the CRC. We will advise you of any important developments during to and subsequent to the contractor transition.

WCRC Contract Under Protest

In a 9/11/2017 article, CMS to Transition to New MSA Review Contractor, we detailed the awarding of the new $60 million, five-year contract, for the Workers Compensation Review Center (WCRC) to Capitol Bridge, LLC. Two of the unsuccessful bidders, Arch Systems, and Ken Consulting, have filed formal protests to the awarding of the contract to Capitol Bridge. The protests are to be resolved by 12/21/2017. It appears then that this will delay the transition to the new WCRC. We will keep you apprised of any notable news on the WCRC transition.