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

CMS, Conditional Payments, Mandatory Insurer Reporting, Medicare Set-Aside Blog on September 23, 2015
Posted by Erin O'Neill, PA-C, JD

On September 17, 2015, CMS held a second 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).

The material presented was virtually identical to the prior webinar held on August 25, 2015 with the exception of a few additional questions answered in the Q & A section held at the end of the webinar.

As previously outlined in our prior blog post, 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). The most significant change will be the generation of a Conditional Payment Notice (CPN) when CMS receives information that an “Applicable Plan” has Ongoing Responsibility for Medicals (ORM). Once again, CMS emphasized that no formal appeal rights exist until the final demand is issued and referred listeners to the prior presentation regarding “Applicable Plan” Appeals presented May 5, 2015.

Barbara Wright began the Question and Answer section of the presentation by stating that if your ORM is working properly, then Medicare will not make any conditional payments and a CPN will not be generated.

It was clarified that where conditional payments have been made, a CPN can be generated at any time, even prior to settlement. Additionally, it is possible that more than one CPN will be issued during the life of the claim.

In response to a question regarding the statutory authority that enables CMS to recover under these circumstances, CMS pointed to the Social Security Act, Section 1862 and 42 U.S.C .1395y (b) and indicated that only primary payment responsibility need be demonstrated, which is accomplished by the Applicable Plan reporting ORM.

One additional interesting issue raised during the Q & A section was with respect to Medicare Part C and Part D plans. CMS indicated that Applicable Plans should contact Medicare Part C and Part D plans directly to resolve any outstanding issues. Information regarding Medicare Part C and Part D plans will be not be available from the CRC.

The remainder of the questions answered involved issues previously addressed in our prior blog post.

The September 17th presentation has been uploaded to the Coordination of Benefits & Recovery Overview website: