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CMS holds town hall call to discuss NGHP conditional payment recovery issues

By Sid Wong, Brian Cowan  |  January 21, 2020

On January 14, 2020, the Centers for Medicare and Medicaid Services (CMS) held its widely anticipated town hall call to discuss recovery issues related to the Commercial Repayment Center (CRC) and on-going responsibility for medicals (ORM) with respect to non-group health (NGHP) claims (e.g., liability, self-insurance, no-fault, workers’ compensation, etc.). The presenters included representatives from CMS, and its two recovery contractors the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC).A copy of CMS’s presentation can be obtained here.

The authors provide the below highlights of the main areas covered during the call, along with practical claims considerations as follows:

CMS provided a basic overview of its recovery process

The panel started the session by providing a general overview of the conditional payment recovery process, which laid the foundation for discussion of the following items:

  • CPL vs. CPN - The first topic addressed was an explanation of the differences between conditional payment notice (CPN) and conditional payment letter (CPL), with CMS stressing that a CPN, unlike a CPL, can automatically progress to a demand and then ultimately a collection action by the Department of Treasury.
  • Disputing unrelated charges- The presenters then shifted to the topic of disputing conditional payment charges that parties believe are unrelated to the underlying claim. They noted that filing a dispute should stop a demand from progressing to Treasury, but any charges that were not successfully disputed would continue to accrue interest. Additionally, it is critical that disputes are filed timely, otherwise, the disputes will be dismissed, and the dismissal will not be vacated unless there were proper grounds for the delay.
  • CRC vs. BCRC recovery - The panel also addressed the recovery handling difference between the CRC and BCRC recovery processes, explaining that the CRC process is used to seek recovery before a TPOC occurs. Unfortunately, the presenters did not address the current issues caused when recovery starts at the CRC with a NGHP debtor prior to settlement and then switches to the BCRC and the Medicare beneficiary after TPOC.

Pre-CPN Worksheets are available again

Of note, the CRC announced that the Pre-CPN worksheet is once again available. By way of background, the Pre-CPN worksheet is a list of all open recovery claims associated with a NGHP debtor and the worksheet is intended to be used to identify debts that will not be disputed. These acknowledged undisputed debts will subsequently trigger the CRC to send CPN for the claim within 90 days. In the fall of 2019, the CRC made the Pre-CPN worksheet, but this was short-lived as CMS quickly put a hold on the process until it had a chance to assess the process. Based on information discussed on the Town Hall call, Pre-CPN worksheets are now back and available for request.

Regarding the Pre-CPN worksheet, the following are key items to consider:

  • Pre-CPN worksheets are 100% optional and there is no requirement to use it;
  • Only the NGHP debtor, the RRE Account Manager, or the MSPRP Account Manager can request the Pre-CPN worksheet;
  • It is available quarterly;
  • The request for the Pre-CPN worksheet must be accompanied by the TIN# and the RRE ID#;
  • The Pre-CPN worksheets will contain a claim number and the amount of the debt, but it will not contain an itemized list of charges; and
  • The Pre-CPN worksheet is not for disputing specific charges.

From a practical standpoint, the Pre-CPN worksheet appears to be a way for the CRC to move forward with issuing CPNs, knowing that subset of claims will not be disputed.

At the same time, there are some practical considerations regarding the Pre-CPN worksheet that we recommend be resolved prior to utilizing the Pre-CPN worksheet as a primary means of identifying and resolving debt including the following points:

  • The CRC did not address what specific information would be included in the Pre-CPN worksheet. In prior state, the Pre-CPN did not provide an itemized list of charges, so there was no way for a payer to validate that charges were related to accepted conditions. If itemized charges are not included in the new version, the utility of the Pre-CPN worksheet is significantly reduced.
  • The CRC has not addressed the potential volume issues that requesting a Pre-CPN worksheet may cause for a debtor if the resulting CPNs are issued in bulk.
  • The CRC did not address how to handle instances where duplicate claims appear on the report, which happened when the Pre-CPN worksheets were originally issued.

Our recent article provides additional information on this process, including consideration points questioning the potential usefulness of this option.

Accessing the Open Debt Report

The CMS panel also spent some time discussing the Open Debt Report and how to access it in the Medicare Secondary Payer Recovery Portal (MSPRP). The Open Debt Report was made available through the MSPRP in October 2019 and is an on-demand report which is available only to the MSPRP Account Manager.

The Open Debt report is intended to provide a comprehensive and current list of a NGHP debtor’s conditional payment recovery debt. It provides the amount owed, the date the demand was issued, and the current status, which is updated nightly. As a result, it is a highly useful tool which provides an overview of outstanding conditional payment exposure, giving debtors a roadmap to track and act before debts become overdue.

There are still some questions regarding the accuracy of the open debt report since some NGHP debtors have indicated that the report shows very few, or no debt cases at all, despite demands being issued by the CRC. Unfortunately, the Town Hall did not provide any substantive answers to this issue, and instead referred any questions about the Open Debt report to the CRC call center at 1-855-798-2627.

Other Issues

At the end of the presentation a significant portion of the Town Hall was devoted to a question and answer period and during this session the CRC presenters provided some additional insight and comments on existing recovery issues and hot topics.

  • Statute of Limitations
    • CRC reiterated its position that the three -year statute of limitations does not apply to the collection actions by the CRC or the BCRC. Rather, from the CRC’s view, it applies only to attempts by CMS to bring legal action to recover double damages.
  • Grouper Algorithm Issue
    • This item relates to the algorithm, commonly referred to as the “grouper algorithm,” used to identify which charges are related to the covered conditions in the underlying case. The CRC acknowledged that the algorithm often includes unrelated charges and that this continues to be an issue. As a result, the CRC has reportedly engaged an internal resource and an outside contractor to review ways to improve the grouper algorithm.
  • ORM and TPOC at the same time
    • CRC indicated that they only recover for debt prior to report of TPOC and if ORM Termination and TPOC is reported at the same time, then the debt goes to the BCRC.

Claims Considerations

In the bigger picture, CMS’s town hall brings into focus a few current issues warranting attention.

First, it is important that CPNs are addressed promptly, and that front-line claims handlers understand the 30 day timeline to dispute any unrelated or inappropriate charges. Keep in mind that the CRC is holding parties to the 30 day dispute deadline and is actively sending delinquent debts to the United States Department of Treasury for collection. Second, the recent availability of the Pre-CPN Worksheet provides an additional tool for NGHP debtors to understand the volume of open leads with the CRC, but claims payers really should assess the usefulness of the worksheet within the recovery process. On this item, until the CRC provides more comprehensive information on the Pre-CPN worksheet, we believe the Open Debt report is a more actionable resource for identifying, analyzing, and resolving the actual exposure for NGHP debtors.

Finally, the CRC’s grouper algorithm remains a significant problem as acknowledged by CMS on the call. As noted above, the CRC is reportedly taking steps to better understand the cause of the problem, but it does not appear that a solution will be presented any time soon. Until the CRC gets a handle on the grouper algorithm, it is even more important that parties actively review and dispute conditional payments to avoid paying for unrelated charges or accruing interest.

ISO Claims Partners will continue to monitor developments on all these fronts and provides updates as follows. In the interim, please do not hesitate to contact Sid Wong or Brian Cowan if you have any questions.

How we can help

ISO Claims Partners is the industry leader in addressing and reducing conditional payment claims. We can assist you in all facets of Medicare conditional payment and Treasury collection actions, including building best practices and training programs. In, 2018 we saved our clients $43 million in conditional payment disputes. We offer a wide array of services to address Medicare conditional payments, Treasury collection actions, and Medicare Advantage lien claims.


Sid Wong is assistant vice president of policy at ISO Claims Partners, a Verisk business. You can contact Sid at swong@verisk.com.

Brian Cowan is legal director at ISO Claims Partners, a Verisk business. You can contact Brian at bcowan@verisk.com.