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Medicare conditional payment round-up | CMS trends, CRC updates, post-settlement TPOC beneficiary recovery and more

By Shawn Johnson  |  November 10, 2020

Pandemic or not, there has been no slow-down when it comes to new CMS trends and CRC updates regarding Medicare conditional payment issues. This year, CMS has been quite active announcing several updates to its Medicare Secondary Payer Recovery Portal and holding a recent webinar on redetermination requests. CMS trends regarding post-settlement TPOC beneficiary recovery have been causing some challenges for workers’ compensation carriers from another angle. CMS will also be holding a webinar on the NGHP Beneficiary Recovery Process on December 9th

To help keep it all straight, the author outlines these key updates and trends as follows:

MSPRP Enhancements

Over the past several months, CMS has rolled out several updates and enhancements intended to increase the functionality of the Medicare Secondary Payer Recovery Portal (MSPRP). In July, the MSPRP was updated to allow users to download and print outgoing correspondence directly from the MSPRP. This will enable beneficiaries or authorized representatives logged in using multi-factor authentication (MFA) to download a copy of correspondence issued by Medicare’s contractors directly from the MSPRP.

Other recent updates have focused on increasing the amount of information available on the MSPRP. As part of the July update, the “case information” screen on the MSPRP was updated to reflect when ongoing responsibility for medicals (ORM) is present on a case. The screen also shows when the case has been referred to the Department of Treasury for collections. 

In October, CMS updated the claims listing page to allow an authorized and authenticated user to sort and filter the listing of charges Medicare is seeking reimbursement for using several columns. As part of this update, users can sort and filter by claim control ID, provider name, date of service, total charged amount, dispute submitted date, or dispute decision date. Further, there is now functionality that allows authorized and authenticated users to export the listing of charges to an Excel spreadsheet. 

CRC focus on redetermination requests

In September, CMS and the CRC held a webinar session to address “redetermination” requests as part of the administrative appeals process regarding conditional payment disputes of non-group health plans (NGHP). CMS reviewed the five levels of the administrative appeals process before the CRC discussed the various appeals available to primary payers in the administrative appeals process. 

The CRC outlined the specific arguments it will accept as part of a redetermination request as follows:

  • Termination of Ongoing Responsibility for Medicals (ORM) due to benefits exhaustion;
  • Termination of ORM due to settlement or other claim resolution;
  • Benefits denied/revoked by applicable plan;
  • Non-covered services;
  • Unrelated services; and
  • Duplicative primary payment.

In addition to understanding the types of appeals the CRC will accept, the CRC stressed debtors must provide the correct information and documentation required for each argument to maximize the chances of a favorable redetermination.

As part of this session, the CRC emphasized adherence to established appeal timelines and other related requirements is critical. On this point, the CRC advised redeterminations must be received within 120 days from the date a Medicare demand letter is received by the named debtor, which CRC noted is presumed to be five days after the date of demand. 

It is crucial to adhere to stated timelines to avoid referral to the U.S. Department of Treasury and potential collections under the Treasury Offset Program and ensure the applicable contractor reviews an appeal.

Post-Settlement (TPOC) Beneficiary Recovery

On another front, under CMS’s current process, the CRC continues to be the contractor responsible for Medicare conditional payment recovery on claims where the primary payer reports ORM. Simultaneously, the Benefits Coordination & Recovery Center (BCRC) handles recovery initiated by total payment obligation to claimant (TPOC) reporting.

As part of this set-up, claims handlers and attorneys must be aware that the BCRC may issue a conditional payment final demand to the Medicare beneficiary after CMS’s receipt of a TPOC report. This is in addition to any recovery that had previously occurred due to the CRC’s recovery against the primary payer based on reported ORM. Given this process, parties should be aware and have a plan to handle a potential post-TPOC recovery case where the Medicare beneficiary is the identified debtor.

CMS’s trend of having the BCRC pursue the claimant post-settlement is currently causing some challenges and frustration particularly in workers’ compensation settlements. Specifically, the BCRC is increasingly opening conditional payment recovery cases upon receipt of TPOC information and issuing final demands with the claimant named the debtor. This occurs even in situations where the parties have previously worked with the CRC to resolve conditional payment cases related to ORM. When this happens, the carrier cannot interact with the BCRC on the claim without having a separate Proof of Representation (POR) executed by the claimant. This, in turn, complicates the workers’ compensation carrier’s ability to ensure that Medicare’s recovery is resolved if they cannot secure a POR from the claimant post-settlement. To prevent this, workers’ compensation carriers wishing to ensure conditional payment exposure is fully resolved may need to consider securing a POR from the claimant as part of the settlement process to avoid having to chase the claimant post-settlement for this required authorization.

Further complicating matters, appeal options may be more limited with the BCRC. For instance, the fact that there has been a settlement may leave the BCRC unwilling to reduce a conditional payment demand to zero in a denied claim. In the future, it will be crucial for settling parties to be aware of the potential of a post-TPOC conditional payment recovery case initiated by the BCRC. They should have a plan to resolve such a case, even in situations where the parties believe the claim's conditional payment portion has been resolved with the CRC.

CMS to hold NGHP Beneficiary Recovery Process Webinar on December 9th

CMS has recently announced that it is holding a Non-Group Health Plan (NGHP) Beneficiary Recovery Process Webinar on December 9, 2020, at 1:00 p.m. ET. CMS indicates that its primary intended audience is “attorneys who represent beneficiaries and other beneficiary representatives.”  

During this webinar, CMS will focus on the MSP recovery process when a Medicare beneficiary receives a settlement, judgment, award, or other payment. They'll also provide a "refresher" on the beneficiary recovery process, including what functions can be facilitated using the (MSPRP). Lastly, they'll provide information on its alternative demand calculation options (Self-Calculated Conditional Payment Amount and Fixed Percentage Option) and beneficiary recovery tips and best practices. Parties interested in attending CMS’s webinar should follow the registration information as outlined in CMS’s notice

How ISO CP Can Help

Please do not hesitate to contact the author if you have any questions or would like further information on how ISO Claims Partners can help you address your conditional payment claims. We offer several cost-effective and proven compliance solutions to help you stay compliant and reduce your conditional payment exposure, including our programmatic CP Link. In 2019, we saved our clients $110 million in conditional payment disputes and reduced 65% of conditional payment dispute submissions to zero dollars. Our CP Link solution saved our clients over $14 million in 2019 and $11 million so far in 2020.


Shawn Johnson is legal director at ISO Claim Partners, a Verisk business. You can contact Shawn at shawn.johnson@verisk.com.