CMS Webinar Regarding Changes to the Non-Group Health Plan Recovery Workload

Medicare Set-Aside Blog, News and Events on August 25, 2015 | Posted by Erin O'Neill, PA-C, JD

On August 25, 2015, CMS held a webinar outlining the changes in workload processes and procedures in preparation for certain Non-Group Health Plan (NGHP) recovery activity to transition from the Benefits Coordination & Recovery Center (BCRC) to the Commercial Repayment Center (CRC).

Effective October 5, 2015, the CRC will assume the responsibility for conditional payment recovery activities in all situations where CMS is pursuing recovery directly from certain NGHPs (also defined as Applicable Plans) including workers’ compensation entities, liability insurers (including self-insured entities) and no-fault insurers. The BCRC will continue to handle recovery activities where CMS is pursuing recovery directly from the beneficiary. It is important to note that all cases initiated with the BCRC will remain with the BCRC. Parties should continue communicating with the BCRC, even after October 5, 2015. CMS indicated that is important to review all correspondence carefully and respond to the correct entity outlined in the letter, either the BCRC or the CRC.

The most significant change noted by CMS is with respect to the generation of a Conditional Payment Notice (CPN). After October 5, 2015, a CPN will be generated when CMS receives information that an “Applicable Plan” has Ongoing Responsibility for Medicals (ORM). The CPN will advise the applicable plan what actions need to be taken prior to the issuance of a Final Demand. The CPN will include a Statement of Reimbursement (SOR) which will outline all the Part A and B medical claims where a conditional payment has been made by Medicare. The CPN will explain how to dispute items/services if applicable. If no dispute is received, or if undisputed claims remain or additional claims have been discovered, a final demand will be issued in 30 days. The demand letter will provide information and instructions for disputing additional claims and/or requesting an appeal. Deadlines and the correct address to send the appeal to will also be noted in the letter. It was emphasized that no formal appeal rights exist until the final demand is issued. (Refer to the “Applicable Plan” Appeals presented May 5, 2015 https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/InsurerServices/Downloads/Applicable-Plan-Appeals-Presentation.pdf)

In those situations where CMS receives notification of a claim by the beneficiary and not through MMSEA reporting or other means, a Conditional Payment Letter (CPL) will be issued instead. The CPL will also include instructions for disputing a claim; however, there will be no response due date.

CMS emphasized that it is important to have procedures in place to review all correspondence and to be prepared to act on all correspondence received from the CRC. Applicable plans can appoint a recovery agent, through Section 111 reporting; however, written authorization will still be required for appointed agents to correspond with the CRC or BCRC once a demand letter is issued. Additionally, written authorization will be required for any agent to file an appeal.

Due to technical difficulties, the webinar will be repeated on September 17, 2015. Additional questions not covered during the Q&A section will be reviewed and additional information may be included during the second presentation. Following this second presentation, CMS will post the webinar to the Coordination of Benefits & Recovery Overview website: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Overview.html

CMS recommended all interested parties sign up to receive notification of updates through the following link:

https://public-dc2.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_7846′>Click to subscribe</a>