CMS Alert: Introducing Recovery Agents

By Shawn Deane November 17, 2014

The Centers for Medicare and Medicaid Services (CMS) has released a technical alert outlining the role of a designated recovery agent in Medicare Secondary Payer (MSP) compliance.

By technical alert dated November 10, 2014, CMS announced that beginning on July 13, 2015 Responsible Reporting Entities (RREs) will be permitted, through the Section 111 Reporting process, to appoint a Recovery Agent. As support for implementing this new procedure, CMS recognized that RREs utilize separate agents – sometimes those other than their Section 111 reporting agent – to conduct Medicare conditional payment compliance activities. Existing Section 111 file layouts do not accommodate fields to include a separate Recovery Agent. New fields will be incorporated into the Section 111 TIN reference layout to allow an RRE to identify a Recovery Agent. Along with the RRE, a designated Recovery Agent will receive copies of all Medicare recovery (i.e. conditional payment) correspondence associated with Section 111 claim reports for that RRE.

If a recovery agent is not identified, the RRE will continue to receive recovery correspondence at the address provided in the TIN Reference File. While designating a recovery agent is optional, CMS indicates that, “RREs are encouraged to use the new reporting methodology as both the RRE and recovery agent will be copied on recovery correspondence.”

In addition to the Recovery Agent’s ability to automatically receive correspondence, the alert also indicates that:

CMS will utilize the designation of an agent and submission of that agent’s name and address on the TIN Reference File/DDE Submission, as an authorization by the RRE for the agent to resolve any recovery correspondence related to claim submissions with a matching RRE ID, TIN and Office Code/Site ID combination. CMS will consider the RRE bound by the agent’s actions on such matters. (Emphasis added).

It appears that CMS will allow a designated Recovery Agent to act on behalf of the RRE for the purposes of conducting conditional payment investigations. While it is still too early to tell, for certain recovery cases, it would appear that traditional Proof of Representation (POR) or Consent to Release (CTR) authorization validation may not be a requirement for the Recovery Agent following implementation of this process in July 2015.

What is the practical impact of this Alert?

Here, CMS creates a process to designate the Recovery Agent via the Section 111 feed. The concept of a Recovery Agent is familiar to insurers who utilize outside companies to obtain conditional payment information and file disputes. This alert makes it easy for an RRE to ensure that their conditional payment compliance needs are being met and further – by designating a Recovery Agent – facilitates the RRE’s compliance with MSP obligations.

How can ISO Claims Partners help?

ISO Claims Partners’ CP Link service connects Section 111 data and conditional payment information and effectively automates the conditional payment process. CMS’ new Recovery Agent designation will support CP Link by facilitating the proper routing of conditional payment correspondence. After reviewing CMS’ alert, we believe RREs will have opportunities for some simple but effective strategies to could greatly improve MSP compliance results as a result of this new policy. ISO Claims Partners commends CMS for further integrating and streamlining components of Section 111 reporting and the Medicare conditional payment compliance process. These enhancements will benefit all parties involved in MSP compliance efforts.

Please feel free to contact Shawn Deane at sdeane@iso.com with any questions about this alert or how ISO Claims Partners can assist with conditional payment questions.


Shawn Deane

Shawn Deane is vice president of product development at ISO Claims Partners where he concentrates on all facets of Medicare Secondary Payer (MSP) compliance. Before joining ISO Claims Partners, he practiced healthcare law and insurance defense. Shawn is a member of the Defense Research Institute, has attained the Medicare Set-Aside Certified Consultant (MSCC) certification, and is the 2017 President of the National Alliance of Medicare Set-Aside Professionals (NAMSAP). He is member of the Massachusetts Bar and is licensed in both state and federal courts in Massachusetts.