Self-Calculate Final Conditional Payment Amount Prior to Settlement

Medicare Set-Aside Blog on February 21, 2012
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Beginning February 21, 2011, CMS implemented an optionpermitting certain Medicare beneficiaries the ability to self-calculate Medicare’s conditional payment amount prior to settlement. As with other recent policies, the option is available only to liability insurance (including self-insurance) settlements and not workers’ compensation or no-fault claims and only when involving a physical trauma based injury and not ingestion, implantation or exposure. The dollar threshold was established at $25,000 or less and the date of incident must have occurred at least six months prior to the submission of the self-calculated amount to Medicare for review. The beneficiary must demonstrate that treatment has been completed and that no further treatment is expected through written physician attestation or a written certification by the beneficiary that there was no treatment for at least the 90 days prior to submission and that there is no further care expected.Election of this option bars beneficiary from appealing the amount or existence of this debt, but the right to pursue waiver of recovery will remain.

Within 60 days MSPRC will send notice of its determination. If it agrees, the beneficiary will receive a letter stating that the amount is considered final as long as settlement occurs with 60 days from the date of the letter and that the settlement is less than $25,000. If it disagrees yet the beneficiary was eligible for the process, it will counter with the amount it determines appropriate. Upon settlement the beneficiary is expected to send the first and last page of the settlement agreement showing the total amount of the settlement and the date it was signed, proof of the procurement costs and the MSPRC’s letter. Upon receipt, MSPRC will adjust for procurement costs and issue a demand for payment within 20 days.

While a nice gesture on CMS’ part, this process does not appear to alleviate much of the time involved in resolving the conditional payment obligations. Prior to evoking this option, the CPL must already have been requested and and that represents the most significant part of the delay. The you still have to go back and forth with MSPRC to dispute unrelated items on the CPL, so it is unclear what advantage this process brings given that the beneficiary must give up the ability to appeal to utilize it.

For more information, visit the MSPRC website at: