Changes to the Non-Group Health Plan Recovery Workload

CMS, Conditional Payments, ICD-10, Mandatory Insurer Reporting, Medicare Set-Aside Blog, News and Events on July 1, 2015
Posted by Erin O'Neill, PA-C, JD

Following the 2013 transition of most Group Health Plan (GHP) recovery activity to the Commercial Repayment Center (CRC), CMS has announced that certain Non-Group Health Plan (NGHP) recovery activity will also be transitioned to the CRC in the near future.

Effective October 2015, the CRC will assume the responsibility for conditional payment recovery activities in all situations where CMS is pursuing recovery directly from certain NGHPs including workers’ compensation entities, liability insurers (including self-insured entities) and no-fault insurers. The BCRC will continue to handle all cases where CMS is pursuing recovery directly from the beneficiary.

Additionally, CMS has announced that on January 1, 2016, CMS’ claims processing contractors will begin utilizing information provided by workers’ compensation entities and insurers reporting Ongoing Responsibility for Medicals (ORM) for specific care, to determine whether Medicare is able to make payment for those claims. CMS has emphasized the importance of reporting accurate ICD-9 and ICD-10 codes, as Medicare’s claims processing contractors will be utilizing this information to determine if payment of certain claims should be made.

Upcoming webinars and town hall meetings will be scheduled to provide additional information regarding these changes. For additional information click here.