Conditional Payments Continue; Designating a Recovery Agent Could Help

CMS, Conditional Payments, Medicare Set-Aside Blog on May 26, 2020
Posted by Jean S. Goldstein, JD, CMSP

In the face of the pandemic, which continues to impact our daily lives, one thing remains constant:  conditional payments. A conditional payment occurs when Medicare makes a payment on behalf of a beneficiary for medical treatment services when payment should have been made or reasonably could be expected to be made by a primary payer. To put into perspective the impact conditional payments make, consider that in the fiscal year 2018, Medicare conditional payment collections totaled $126.57 million [1]. While the world around us continues to be impacted by the Coronavirus, Medicare beneficiaries are still treating, whether it is through telehealth or with treatment providers. It is very likely, that amidst the current challenges there will be additional Medicare payments made during this time, for which another payer is responsible.  

Despite the various obstacles and challenges that have come along with the pandemic, there are still specific time frames and deadlines which must be adhered to as related to conditional payments. Failing to meet these deadlines may result in a Responsible Reporting Entity (RRE) losing the opportunity to dispute any unrelated payments, and potentially result in additional exposure and/or additional costs. In 2014, many of us could not predict that a pandemic would impact our daily lives or our workflows and that it would be helpful to have a compliance partner standing ready to facilitate meeting Medicare Secondary Payer obligations. Yet, here we are with many of our fellow teammates still working from home or working in offices on rotating schedules. In 2014, non-group health plan (NGHP) RREs were provided a solution to designate a Medicare Secondary Payer Recovery Agent.  The purpose of appointing a Recovery Agent then, and now, is to provide the Centers for Medicare & Medicaid Services with the name of an entity that is authorized to do work on behalf of the RRE as related to Medicare Secondary Payer Recovery claims. By doing so, the Recovery Agent is authorized to receive a copy of all correspondence related to conditional payments and recovery demands associated with the NGHP. The RRE continues to receive recovery correspondence directly, but the Recovery Agent designation removes the added effort and required coordination of sending correspondence to an entity or company authorized to assist with the conditional payment recovery process.  

Medicare conditional payment notices, letters, and demands must be timely resolved, and naming a Recovery Agent is one sure way to ensure that conditional payments are addressed efficiently, effectively, and within all required time frames. Most importantly, during this unprecedented time, having a Recovery Agent means that any potential lag in time due to mail processing has been removed. Designating a Recovery Agent is a quick, and easy process, which results in peace of mind that Medicare Secondary Payer obligations will be met.  With the potential for additional Medicare conditional payments, it is vital that the best practices and protocols of investigating, negotiating, and resolving conditional payments continue. With conditional payments, perseverance and diligent advocacy truly pay off. At MEDVAL, we have established a tried and true process to address conditional payments and mitigate exposure that enables us to get the best results possible. For more information about establishing MEDVAL as your Recovery Agent, please contact us at info@medval.com.


[1] https://www.cms.gov/files/document/medicare-secondary-payer-commercial-repayment-center-fiscal-year-2018pdf