Non-Group Health Plans Commercial Repayment Center

On August 25, 2015, The Centers for Medicare and Medicaid Services (“CMS”) held a webinar to explain when and how Non-Group Health Plans (“Applicable Plans”) will use the new Commercial Repayment Center (“CRC”). Beginning October 5, 2015, the CRC will be responsible for cases where CMS is seeking reimbursement directly from the Applicable Plan. When an Applicable Plan reports Ongoing Responsibility for Medicals (“ORM”), CMS will issue a Conditional Payment Notice (“CPN”) to the Applicable Plan and if the CPN is not disputed within 30 days a Demand Letter will be issued to the Applicable Plan. Thereafter, interest will be assessed on Demand Letters.

The Benefits Coordination and Recovery Center (“BCRC”) will continue to be responsible for the lien resolution process for files where the BCRC seeks reimbursement from the beneficiary. Therefore, the process for plaintiff attorneys who are resolving Medicare liens for clients will remain the same.

An outline of the process for resolving liens follows:

Prior to October 5, 2015:

• No changes from current process:
  • BCRC is responsible for issuing conditional payment listings (“CPL”);
  • BCRC is responsible for handling the reimbursement;
  • Applicable Plan reports ORM and no CMS action taken until Plan reports the ORM termination date.

Effective October 5, 2015:

• What stays the same:
  • BCRC will continue to administer lien reimbursements where CMS seeks recovery from the beneficiary;
  • BCRC will continue to issue a Conditional Payment Letter when the beneficiary reports a case and Medicare has a made a conditional payment.
• What changes:
  • The new CRC will handle all reimbursement activity where CMS is seeking recovery directly from Applicable Plans;
  • A Conditional Payment Notice (“CPN”), will be immediately issued when an Applicable Plan reports the opening date for on-going responsibility for medicals (“ORM”);
• The CRC will:
  • Notify the Applicable Plan of steps required prior to issuing a Final Demand;
  • Include a Statement of Reimbursement (“SOR”) listing conditional payments made by CMS for Part A and B, fee for service, claims;
  • Will include instructions for disputing a claim and the appeal process;
  • Will issue a Final Demand.

What to be aware of:

• Any case initiated with the BCRC, regardless of date, will continue to be handled by the BCRC;
• Carefully review the documentation received to ensure that you are responding to the proper agency (BCRC or CRC);
• Carefully review ORM files before submission to ensure accurate ICD 9/10 codes are reported;
• Authorizations will be required to correspond with the CRC or BCRC;
• Prior to October 5, CMS used the information received via the Section 111 reporting of ORM to ensure that CMS did not pay for on-going medicals for the subject injury;
• Beginning October 5, CMS will not only be protected from incurring future medical expenses, but will immediately seek reimbursement, from the Applicable Plan, if Medicare has paid for expenses from date of injury to the date of assumption of ORM.

How will this affect the process?

After October 5, Applicable Plans will have to audit CPNs to determine whether all expenses are related to the ORM or the Applicable Plan will have to repay CMS for any medical items or services listed on the CPN, whether related or not.

Applicable Plans will need to include in their claims process, steps to ensure that they are reviewing CPNs and disputing them where appropriate. If conditional payments were made by CMS, the Applicable Plans must be ready to reimburse Medicare upon the opening of ORM.

This webinar will be offered again on September 17, 2015, and the presentation may be updated to address questions raised since the webinar on August 25th. Following the September 17th webinar, CMS will post a transcript as well as the slides to its website. GRG will provide that link when it is available.

The Garretson Resolution Group continues to monitor developments at the CMS and will report future developments. For more information about this announcement and other MSP compliance services, please visit www.garretsongroup.com.