Take-Aways from Recent NGHP Town Hall on Conditional Payment Recovery, Section 111 Reporting


As mentioned in our recent blog, the Centers for Medicare & Medicaid Services (CMS) recently hosted a Town Hall on April 1st.  As a recap, John Albert of CMS introduced the Town Hall and stated that the purpose was to address the Commercial Repayment Center (CRC) recovery process and the intersection with the Benefits Coordination & Recovery Contractor (BCRC), including MMSEA Section 111 reporting. Mr. Albert noted that any MSA questions/questions related to MSP future medical obligations should be held for a future call. Additionally, no MMSEA Section 111 Civil Monetary Penalties (CMPs) questions would be addressed.

Mr. Albert further noted that no new information would be provided on the call; thus, there would be no publishing of new materials after the Town Hall.

For those not familiar with contractor responsibilities he noted that:

o   BCRC – pursues recoveries where the beneficiary is debtor. Additionally, the BCRC manages front-end coordination of Medicare benefits as it relates to MMSEA Section 111 data.

o   CRC – pursues recoveries where the Non-Group Health Plan (NGHP) insurer. The CRC is also involved where the workers’ compensation or no-fault entity is the debtor and ORM has been reported.

o   Note: Important to respond directly to the entity sending correspondence, no matter where in the process the recovery is. Additionally, checks should be sent only to the appropriate contractor per the correspondence received.

Next, the BCRC and CRC dove into some frequently asked questions involving the intersection of Section 111 reporting and conditional payment recoveries. Many of these scenarios involve complex claims with multiple injuries and settlements that are beyond the scope of this blog.

Below are a few of the more noteworthy Mailbox and Live Q&A presented to CMS:  

Q: Does an RRE have to report if beneficiary refuses to provide SSN?

CMS: This can be an issue, as the beneficiary may not cooperate. RREs should make sure to document all attempts to obtain the claimant’s SSN. Model language for communication with the beneficiary is provided on cms.gov. The Main takeaway is that the RRE document the details of its attempts to obtain the SSN.

Q: Why do we receive new letters with new claims/payments after sending a dispute for unrelatedness?

BCRC: If there is an ORM term date reported, the payments could be before the ORM term/TPOC date. If no term date/TPOC, Conditional Payment Notices (CPNs) will continue issue.

Q: How do we prevent cases from going to the treasury when in the appeal process?

CRC: When there is a formal appeal or reconsideration, the debt is placed on hold and can be recalled from the treasury. If the debt is at the ALJ level, the CRC needs to be copied to be made aware to place on hold. The ALJ does not copy the CRC; thus, they need to be made aware.

Q: The Current time to appeal conditional payments is 120 days. If this deadline is missed because of oversight, and charges are completely unrelated, is there any further recourse or is the debtor stuck with the charges? Specifically, with no explanation other than it was a mistake?

A: If the debtor missed the deadline, a response letter will be issued with instructions. The beneficiary will not be required to pay, and a higher level of appeal can be pursued. Appeal rights are still available.

Later clarification: 120 calendar days plus 5 days for mail time after demand is required for a response. A cause is needed for delay for redetermination. If not, the appeal will be dismissed.

Q: If we have a MedPay case and are unsure of the liability case, which do we send under?

A: Section 111 – only report if liability for medical. Hold off on reporting until you know there is liability.

By Heather Schwartz Sanderson

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