On August 9, 2019, the Commercial Repayment Center (CRC) hosted a conference call to discuss the handling of conditional payment letters (CPL) versus conditional payment notices (CPN). On this call, the CRC announced that due to the high volume of conditional payment “leads” created from parties self-reporting their claims to the Benefits Coordination and Recovery Center (BCRC) outside of the Section 111 reporting process, they’re looking to reduce their outstanding backlog of 338,819 leads.
Accordingly, to streamline its workload, the CRC emphasized its desire to focus on recoverable debts and noted that a CPL is a notification of potential debt and is intended to be used by the debtor to review, update, or delete the corresponding lead. Notwithstanding, the debtor could also decide to accept the debt and obtain a demand. Consequently, the CRC alluded to shifting away from processing fully disputed CPLs since they do not result in a recoverable amount and parties will not be able to obtain confirmation of a $0.00 CPL. While this tactic may result in less work for the CRC, it eliminates an existing and critical tool for the debtor to be able to proactively review and correct erroneous recovery charges.
Before the CRC’s proposed changes, CPLs were effectively used to identify the potential recovery charges prior to settlement and to minimize the anticipated recovery debt post-settlement – all proactively handled outside the timing of a CPN. If the CRC implements the new CPL handling, it would be a substantial deviation from its historical practice and removes opportunities for debtors to ensure that exposure to conditional payments are accurate and up to date throughout the life of a claim. Due to the potential impact of this change, we are seeking additional information and guidance from both the CRC and the Centers for Medicare and Medicaid Services (CMS) on the issue.
During the call, the CRC also addressed the importance of accurately reporting the data concerning CMS’ TPOC (total payment obligation to the claimant) and ORM (on-going responsibility for medicals) reporting triggers as means to minimize errors. However, we have observed that Section 111 data may not be the primary source of discrepancies. A component of ISO Claims Partner’s dispute process is to review a claim’s Section 111 reported ICD codes (if available) to confirm related injuries and treatment. In many cases, when this is compared against a claim’s CRC payment summary form (PSF), it is evident that the CRC is still including treatment completely unrelated to the reported codes. While we agree that accurate Section 111 data is critical, ISO CP has advocated for the CRC to review the scope and impact of its grouper algorithm on unrelated treatment which, if made more accurate, should reduce its dispute volume and workload. To date, we continue to see significant inclusion of unrelated treatment in recovery letters. When the grouper is overbroad, the CRC is essentially seeking recovery for treatment of which Medicare may not be the secondary payer and further highlights the importance of the CPL as a tool to monitor and correct PSF charges.
On another front, the CRC has begun to issue Pre-CPN worksheets. This is another tool the CRC is using to maximize its recovery resources. These worksheets rely on the RRE debtor to actively identify erroneous charges for the CRC so it can narrow the scope of recoverable debt. However, if recovery charges are disputed directly from the Pre-CPN worksheet, the CRC may directly issue a formal demand and bypass the issuance of a CPN if any recoverable charges remain. In this situation, without a CPN and the corresponding 30-day response period, the debtor may be negatively impacted if the demand includes other charges not initially listed on the Pre-CPN worksheet. Notably, the charges listed on Pre-CPN worksheet are not yet considered debts and the CRC does not currently require Responsible Reporting Entities (RREs) to utilize the Pre-CPN worksheet. As a result, debtors may be better served by using the worksheet to monitor potential disputes while waiting for a CPN or settlement rather than using it to prematurely trigger a demand.
As the CRC works through its backlog, we may see additional process changes or adjustments. The CRC may even decide not to proceed with the handling it discussed on the call. In the meantime, ISO Claims Partners will continue to monitor the current process, advocate for better results, and advise of any other impactful issues. Please contact the author if you have any questions.