Medicare’s Conditional Payment Recovery Process is Ramping Up:  What You Need to Know.

Conditional Payments, CRC, MSP News on November 14, 2018
Posted by Jean S. Goldstein, JD, CMSP

Last month, at the annual National Alliance of Medicare Set-Aside Professionals’ Annual Conference, Performant Financial (Performant), the current contractor for the Commercial Repayment Center (CRC), held a timely panel question and answer session.  You may recall that we recently blogged about how the current conditional payment recovery process continued to terrorize many non-group health plans.  Many of the frustrations associated with the current recovery process can be attributed to several different factors.  Particularly, as with all government contracts, there is always a transitional period from one contract to the next, and some of obstacles encountered by Performant are simply beyond its control.

During the recent question and answer session, Performant discussed the backlog inherited from the former contractor, CGI, which resulted in delays and the required response timeframes not being adhered to.  In addressing the backlog, Performant also indicated that much of the backlog had been cleared as of October 1.  When Performant first came aboard, in an ongoing effort to clear the backlog many non-group health plans began noticing that they were receiving conditional payment letters (CPLs) rather than conditional payment notices, (CPNs).  The difference between these two documents is that there is an indefinite disputing period with a CPL, versus the CPN which has 30-day disputing period before a demand will be issued.   Performant essentially placed CPNs on hold while they worked through the backlog, as described.  Performant also indicated that because the backlog had been cleared, they expected to be ramping up their recovery efforts, such that at least 300 new CPNs would be issued each week, with increased amounts of letters to be issued on ongoing basis.  We can report now, since it has been a month since this initial announcement, that we have certainly seen an uptick in CPNs, and conditional payment recoveries are in fact ramping up.

Performant also acknowledged that CGI would allow disputes and appeals, even if timelines were missed by the client.  However, during the session, Performant emphasized that they would no longer be allowing disputes or appeals to be processed if received after the deadline dates without an explanation of good cause.  Essentially, Performant will disregard any untimely filing without good cause.  Performant also indicated that they will be adhering to their required timeframes.  As a reminder, based upon the type of correspondence, Performant will be expected to review the following types of correspondence from the date of receipt as follows:

  • Disputes: 45 days;
  • Appeals: 60 days; and
  • Settlement Documents: 20 days.

At this conference, it was also announced that CMS was anticipating making continued enhancements to the Medicare Secondary Recovery Portal (MSPRP) this coming April.  You may recall several months ago, when CMS held an informative webinar to address the benefits of using the MSPRP.  It appears that CMS is hoping to have a system in place to process electronic payments by April 2019, which will certainly be a welcomed enhancement.

Lastly, one additional key highlight from the CRC’s session was a brief discussion on third party authorizations.  The CRC was clear that these documents do not need to be limited to a specific time period and can be utilized throughout the lifespan of a claim.  Of note, the MSPRP was also recently upgraded to make the third-party authorization verification process instantaneous.  Prior to this upgrade, an agent authorized to resolve a conditional payment recovery matter would experience a brief delay until the authorization was verified.  With this latest upgrade, there is no longer a delay in having the authorization approved, allowing an agent to begin work on a recovery matter immediately.

Earlier this week, Performant Financial released their Third Quarter Earnings.  Interestingly, they noted that that they “…knew this would be an investment year, [and they] experienced delays in timing of these contracts due to external factors which have now been resolved.”   Performant is likely referring to the backlog that has been addressed.  Moreover, the earnings report, indicates that they have “…continued to build momentum in the MSPCRC contract, which is ramping well.”

All signs point to a huge ramp up in the Medicare conditional payment recovery process.  It can be presumed that we will continue to feel the momentum of Performant as they have worked through their transitional period.

 Key Takeaways and Considerations:

  • The Conditional Payment Recovery Process is Ramping Up.  We heard from the CRC last month, as well as in their earnings report this week that conditional payments are ramping up.  The translation is that recovery efforts are increasing and more than ever before, it is important to create internal protocols and establish a uniform process to address conditional payments and mitigate future exposure as early on as possible.
  • Pay Attention to All Correspondence.  While several months ago, we saw many CPLs being issued, we have now begun to see more CPNs being issued.  This means that applicable plans must pay close attention to the correspondence that is being received and understand the timeframes and deadlines which must be adhered to in order to effectively dispute conditional payments.
  • Consider Designating a Recovery Agent. With increased recovery efforts on the horizon, it may be an appropriate time to consider designating a Recovery Agent.  A Recovery Agent is an entity or organization that will receive, directly from the contractor, copies of all conditional payment recovery correspondence associated with an applicable plan.  Designating a Recovery Agent ensures that a named agent will receive all conditional payment recovery correspondence automatically, and therefore be able to timely, and efficiently respond to all recovery efforts within the required time frames.

We will continue to update our readers on more information, trends, and changes to the Medicare conditional payment recovery process.


About MEDVAL as a Recovery Agent:

One of the many MSP Compliance Solutions MEDVAL offers is serving as a recovery agent.  Through long experience, we have learned that perseverance and diligent advocacy truly pay off.  We have established a tried and true process to mitigate our client’s exposure, as well as a working relationship with the Contractors that enables us to get the best results possible.

For more information about establishing MEDVAL as your recovery agent, please contact us at [email protected].