On Tuesday, August 23rd, CMS held a webinar on the transition for Non-Group Health Plans (NGHP) to the Commercial Repayment Center (CRC). A summary follows on how work will be coordinated between the CRC and Benefits Coordination and Recovery Contractor (BCRC) as both will share responsibility for NGHP recoveries. New process involves new terms, and we highlight them within.
As we predicted, CMS is moving forward with Demand Letters, when Ongoing Responsibility for Medical (ORM) is reported via MMSEA Section 111 reporting. The Section 111 report will cause the CRC to issue a Conditional Payment Notice (CPN) to the Applicable Plan, and if not disputed within 30 days a Demand Letter will follow requiring payment by the Applicable Plan. CMS intends to close the loop on open ORM cases that do not typically have a settlement, judgment or award. Workers’ compensation and no-fault insurance plans should be ready for this change and can expect these letters to issue as early as October 25, 2015. CMS will immediately assess interest on Demand Letter amounts, and will no longer wait 60 days.
Most of the Q&A during the webinar revolved around the roles of the BCRC and CRC, but Barbara Wright of CMS also placed emphasis on the important obligation to protect Medicare’s interest exists whether or not there is a MMSEA report of the case. Repayment to Medicare is a shared responsibility between claimant/counsel and the insurer. Medicare can pursue recovery against any entity directly and it does not matter if the insurer or self-insurer has already paid the money over to the claimant. If the Medicare beneficiary does not repay the demand letter, then Medicare can pursue recovery against the primary plan or individual/entity that received payment from the primary plan. This is why we believe it is important that conditional payments be managed proactively, particularly after ORM is reported, to make certain they are promptly paid.
COB&R/BCRC and CRC will require a time of transition and learning. It is important to read the letters and understand what the type of conditional payment correspondence received. We believe that both contractors will be more aggressive, but even more particular the CRC, because it is paid on a contingency basis it may be more so. Recall that implementation of ICD-10 coding takes place on October 1, 2015, and accurate coding through MMSEA Section 111 data will be more important now than ever.
Conditional Payment Letter (CPL)– CPLs will be issued by the BCRC when a beneficiary self-reports that a liability, workers’ compensation, or no-fault insurance has primary responsibility and Medicare has made a conditional payment. CPLs will be issued only when the MSP instance was not otherwise reported through MMSEA Section 111 Reporting.
Conditional Payment Notice (CPN)- CPNs will be issued by the CRC when an applicable plan has notified Medicare via MMSEA Section 111 Reporting that it has ongoing responsibility for medicals (ORM) and otherwise reports that it has primary payment responsibility.
Statement of Reimbursement (SOR)- This is similar to the BCRC’s payment summary form and will be provided as an enclosure with CPLs, CPNs, demand letters, and redetermination decision.
Disputes- Upon receipt of a CPN, the applicable plan has 30 days to dispute the CPN and may do so only once. If not responded to within 30 days, the CRC will issue a demand letter. To dispute medical claims on a CPN, the applicable plan must submit required documentation within 30 days of the CPN date plus five days for mailing. CPLs have no time limit to respond.
Disputes submitted to the CRC through the Medicare Secondary Payer Recovery Portal (MSPRP) may only be done so on the basis of relatedness and in response to a CPN. All other dispute types must be submitted in writing outside of the MSPRP. If the debtor has more than one dispute for the same case (i.e., relatedness and claims paid to provider), the entire dispute package should be submitted through the mail and not the portal.
Demand Letter-When a demand letter has been issued, it will reflect a “response due date for payment” on the letter. Demand letters issued will have appeal instructions along with the deadline to appeal. Once the demand letter is issued, interest will begin to accrue.
CRC contact information is the following: PO Box: 93965, Cleveland, OH 44101; Fax: 216-583-0228
Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP
Chief Legal Officer