Top five tips to get a handle on conditional payments

By Shawn Deane May 9, 2016

Conditional payments are one of the biggest challenges insurers face when resolving a case with a Medicare beneficiary. The problems that arise include late awareness of Medicare eligibility, difficulty obtaining information from the conditional payment contractor, and discovering that the conditional payment is far more than expected. How do you avoid these issues and gain control of the process? Here are our top five tips:

  1. Identify beneficiaries at the start. The easiest way to avoid conditional payment problems is to identify the issues as early as possible. Medicare has tools to help you identify Medicare beneficiaries, but first you’ll need to obtain the claimant’s five key query data elements. Once you establish whether a claimant is a Medicare beneficiary, you’ll immediately know whether conditional payments could affect your settlement. After you’ve determined this, you’ve already overcome the biggest hurdle.
  2. Go to the right source. Among the recent changes in the conditional payment process is the new system for collections. You now need to communicate with different organizations depending on the type of claim you’re handling. Liability cases still go to the Benefits Coordination & Recovery Center (BCRC). But workers' compensation and no-fault cases are now handled by the Commercial Repayment Center (CRC). Although the CRC is not new, its involvement in workers' comp and no-fault conditional payments recovery is. For information on how the CRC is changing Medicare compliance, take a look at our April webinar.
  3. Act quickly. Because there’s often a time lag in obtaining conditional payment information, once you know you have a conditional payment issue, you should coordinate quickly with the appropriate contractor. The goals of this outreach are twofold: to ensure that the contractor has the correct information about the claim and to obtain the conditional payment amount as soon as possible so you’re ready for the settlement.
  4. Proactively investigate and dispute. Remember that CMS contractors sometimes make mistakes and that the codes on a payment screen don’t always tell the full story. As soon as you receive a conditional payment letter, investigate whether the alleged payments relate to the underlying claim. If they’re unrelated, then aggressively dispute, appeal, and resolve the issues. It’s our experience that almost every conditional payment letter has some charges that can be eliminated due to contractor error or underlying legal or medical reasons. If you simply pay what CMS says you owe, you’re leaving money on the table.
  5. Tie it up. The final step is resolving the claim properly. Make sure your settlement outlines the parties’ conditional payment responsibilities: who is paying Medicare and when. And don’t forget to review the demand closely, especially because there’s now a formal appeals process with specific guidelines. If Medicare’s contractor makes a mistake in the final demand, immediately begin the appeal process. Once you’ve confirmed that you’re responsible, make payment on time, since interest accrues after 60 days.

Still feeling daunted by conditional payments? ISO Claims Partners can help. We were the first major MSP compliance provider to incorporate conditional payment compliance into every referral. Our comprehensive conditional payment program—CP Link—relies on Section 111 data to automate many of the steps and ensure front-to-back compliance. Give us a call to learn more about how to take control of your conditional payment program.


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.