CMS: Medicare Residual Payments for WCMSA Depletion & ORM Termination

CMS, Conditional Payments, Medicare Set-Aside Blog, Medicare Set-Asides on August 13, 2015
Posted by Erin O'Neill, PA-C, JD

On August 6, 2015, the Centers for Medicare and Medicaid Services (CMS) issued instructions for the Shared Systems and Medicare Administrative Contractors (MACs) to follow when a Medicare Residual Payment must be paid on Workers’ Compensation Medicare Set-Aside Arrangements (WCMSA) or for Ongoing Responsibility of Medicals (ORM) Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) Claims.

CMS explained that effective January 1, 2016, with anticipated implementation date of January 4, 2016, Medicare may make a “residual” secondary payment in situations where ORM benefits terminate or deplete or a WCMSA depletes while a beneficiary is admitted to a facility or following a physician or supplier visit, and the claim is not fully paid by the WCMSA or NGHP. A residual secondary payment is defined by CMS as, “a payment Medicare makes on a claim where available funds have been exhausted from the WCMSA or ORM benefit or responsibility for payment terminates mid-service”.

The change request indicated that the Shared Systems, Medicare A/B Administrative Contractors and DME Medicare Administrative Contractors, should pay the residual secondary payment by sending the primary payer payment amounts to the MSPPAY module and calculate Medicare’s payment if services are covered and reimbursable by Medicare. The MSPPAY modules are standardized software utilized by the contractors and Shared Systems to calculate MSP Part A, Part B and other supplier payments, in accordance with 42 CFR 411.33.

The Change Request further provides specific requirements and technical direction for the MACs.