CRC Archives

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.

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.

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.

CMS Releases Annual Report on CRC Conditional Payment Recovery

September 5, 2017

On 8/30/2017 the Centers for Medicare and Medicaid Services released its annual report on the Commercial Repayment Center’s (CRC) Medicare conditional payment collections for the 2016 fiscal year (10/1/2015 through 9/30/2016). In short, the report documents the CRC identified $243.68 million in conditional payments, collected a net of $106.29 million and returned $88.35 million to the Medicare Trust Fund after subtracting collections costs.

The CRC, which is paid on a contingency basis, has responsibility for Medicare conditional payment recovery efforts involving Group Health Plans and Non-Group Health Plans (NGHP). NGHPs are liability insurance (including self-insurance, no-fault insurance or workers’ compensation). FY 2016 was the first fiscal year in which the CRC had responsibility for recovery of conditional payments from NGHPs, a task previously handled by the Benefits Coordination and Recovery Center (BCRC). Recovery claims involving Medicare beneficiaries remain with the BCRC.

A copy of the report may be found on the CMS website here.

Some observations from the report:

CMS does not split out GHP and NGHP recovery information which makes it difficult to ascertain, one, the effect of adding NGHPs to the CRC’s responsibility has had on overall collections and, two, the percentage of overall collections attributable to GHPs versus NGHPs.
Despite identifying $243.68 million on conditional payments, the CRC only recovered $117.40 million, shortly under half (48%) of the identified amounts. This may be the result of the provided data only documenting debts that are identified and collected within the fiscal year. The report indicates that collection of FY 2016 identified debts continues into the next fiscal year.
Connected to the above observation, it is disappointing that the CRC does not provide a more comprehensive multi-year view of its recovery work. Information such as amounts recovered over the past several years, average turnaround time from demand to repayment, and the above-mentioned GHP vs. NGHP data would be invaluable to understanding the overall program.
Provided in the report is a statement indicating amounts returned to the Medicare Trust Fund dropped from $125.05 million in FY 2015 to $88.35 million in FY 2016. CMS attributes the drop to “a decrease in GHP recoveries due in part to the maturity of the mandatory insurer reporting under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 decreasing the instances of mistaken payments, as well as the CRC’s resolution of pending available recoveries.” This drop is nonetheless surprising given that FY 2016 marked the CRC’s first year recovering from NGHPs!

Takeaways

We do not recommend any changes to your Medicare conditional payment resolution program or process based upon the report. The report merely provides a window into the efforts by the CRC at recovering conditional payments from GHPs and NGHPs.

Accuracy in Section 111 Reporting of ORM Vital to Avoiding Unnecessary Repayment Demands from Medicare

July 24, 2017

While the Commercial Repayment Center (CRC) has faced some valid criticism over the course of the past year and half in relation to its recovery efforts on behalf of the Centers for Medicare and Medicaid Services’ (CMS), not all problems start with the CRC. CRC’s recovery efforts are driven by the data employers, carriers and self-insured entities report to Medicare through the Section 111 Mandatory Insurer Reporting process. Chief among the data elements reported is acceptance of Ongoing Responsibility for Medicals (ORM) and the termination thereof. If this data is reported inaccurately or there is a failure to report required data, then the applicable plan may be faced with inappropriate recovery demands by the CRC.

Applicable Plan Reporting of ORM is the Catalyst for CRC Recovery Efforts

Since October 5, 2015, the CRC has had responsibility for the recovery of conditional payments where the insurer or employer (including self-insured entities) is the identified debtor, known in CMS terms as the “applicable plan.” The CRC learns of opportunities to recover through the Section 111 Mandatory Insurer Reporting process. In other words, the applicable plan is the catalyst for Medicare conditional payment recovery by its reporting of ORM.

The mandatory reporting provisions of the Medicare Secondary Payer Act require the applicable plan to report to Medicare in three instances – the acceptance of ORM, the termination of ORM and issuance of a Total Payment Obligation to the Claimant (TPOC), settlement judgment, award or other payment. In regard to ORM, two key data elements reported are the date responsibility for ORM is accepted and the accepted diagnosis codes. Once this information is reported the following actions are initiated by CMS’s contractors:

1. The BCRC, which handles Medicare coordination of benefits, should deny payment for medical bills submitted for payment in which the billed diagnosis codes match or is similar to the reported diagnosis codes.

2. The CRC identifies medical claims that Medicare has paid that it deems related to the reported diagnosis codes.

Upon the CRC identifying treatment related to the reported diagnosis codes, it will issue a Conditional Payment Notice (CPN) to the applicable plan which itemizes charges deemed related to the injury. The applicable plan has 30 days from the date on the CPN to dispute charges after which a Demand Letter will issue demanding repayment for the charges identified by the CRC. A Demand Letter provides 120 days from receipt of the letter for the applicable plan to appeal all or some of the charges or issue payment. If payment is not issued within 60 days of receipt, interest begins to accrue from the Demand Letter date.

Reporting Accurate Acceptance of ORM and Diagnosis Codes

The trigger for reporting ORM is a claimant identified as a Medicare beneficiary and the assumption of ORM by the applicable plan. ORM is reported when the applicable plan has made a determination to assume responsibility for ORM, or is otherwise required to assume ORM—not when (or after) the first payment for medicals under ORM has actually been made. Accordingly, the ORM acceptance date is typically the date of injury.

Along with the ORM acceptance date, at least one ICD-10 diagnosis code must be reported for the diagnosis that has been accepted on the claim (If more than one diagnosis has been accepted, then additional diagnosis codes are reported). While medical provider billing records are often used to determine ICD-10 diagnosis codes to report, these should be used as a starting point, not an ending point, in identifying the correct codes to report to Medicare.

Keep in mind that medical providers, and especially hospitals, will often insert into billing records any diagnosis reported to the provider, which are not necessarily the same diagnoses that are being accepted on the claim. Consequently, the person responsible for determining the correct ICD-10 diagnosis code to report, usually the claims handler, must make an independent determination, separate and apart from the medical provider, as to whether the particular diagnosis is being accepted on the claim. If the billing records do not properly represent what is being accepted, or if further diagnosis codes are required to better define what is accepted, then online ICD-10 resources are available to identify codes which correctly represent the accepted body parts and conditions.

Once ORM and the diagnosis codes are reported, ORM is generally not addressed again until the date of ORM termination. However, causally related diagnoses may change over time, either expanding or retracting depending upon the circumstances in the claim. Accordingly, it is important to update the reported ICD-10 codes as necessary over the course of the claim.

ORM Termination Key to Cutting Off Liability to Medicare

Once ORM is accepted, CMS claims the right to recover against the applicable plan through the date of ORM termination. As such, recovery efforts by the CRC may happen years after the ORM was first reported. Further, if there is failure by the applicable plan to terminate ORM when appropriate, then the plan may receive repayment demands from CRC for time periods in which it has no liability to pay for medical treatment. An applicable plan may terminate ORM through the Section 111 Reporting process under the following situations:

Settlement with a release of medicals

No fault policy limit reached

Complete denial of the claim

Statute of limitations has run or medical benefits have otherwise been exhausted pursuant to state law

Judicial determination after a hearing on the merits finding no liability

Statement from treating physician – signed statement from the injured individual’s treating physician that he/she will require no further medical items or services associated with the claim/claimed injuries.

Keep in mind that closing a claim file is not a trigger for ORM termination unless it is accompanied by one of the above situations.

Providing CMS with an ORM termination gives a bookend to recovery by the CRC. If no termination date is provided, then CRC assumes the applicable plan remains liable for injury-related payments.

Recommendations for Ensuring Accurate ORM Reporting

The reporting of ORM acceptance and termination and defining accepted diagnosis codes is so important because it is the applicable plan’s admission of responsibility to pay for medical care during the reported time period and for the reported diagnoses. If an error is made in reporting or there is an omission in reporting, then it can result in attempts by Medicare to recover for conditional payments unrelated to the injury or for time periods during which the applicable plan is not liable. Errors in reporting can also lead to inappropriate denials in the payment of claimant’s medical care by Medicare or Medicare paying for medical care for which the applicable plan is responsible.

Recommendations to avoid these errors and omissions:

1. Train Claims Handlers on ORM Reporting: If a claims handler is responsible for inserting the data required for ORM reporting, then they require training as to when ORM acceptance and termination is to be reported and how to determine the appropriate diagnosis codes to report with ORM acceptance.

2. Effective Quality Assurance of ORM Reporting: Even with training, errors will occur. Additional resources placed into quality assurance of ORM reporting, such as double-checking claims for proper ORM termination and appropriate diagnosis code choices avoids the expenditure of additional resources at a later date to correct errors in reporting and correction of unnecessary recovery demands from the CRC. If you are an employer or carrier relying upon a TPA to report, it is especially recommended that a QA process be in place to check the data entered by the TPA.

3. Ensure Reporting Platform is Accurately Reporting: Section 111 Reporting is electronically based and requires a data exchange with Medicare. Errors can and will occur in this data exchange. Ensure you have a trusted and reliable reporting agent to assist with accurate reporting to Medicare.

Finally, if any correspondence is received from the CRC or the U.S. Treasury Department claiming conditional payment recovery it must be acted upon immediately. Do not assume the letter was issued in error and will simply go away. If you do not believe you are liable for the conditional payments for which the CRC is claiming recovery, first confirm you have correctly reported ORM and then work with your MSP compliance partner to appropriately dispute the charges.

For questions stemming from this article please contact Dan Anders at (888) 331-4941 Daniel.anders@towermsa.com.

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.