Conditional Payments 101 and a New CMS Electronic Payment Announcement!

Ever wonder why it is so difficult to resolve Centers for Medicare and Medicaid Services (CMS) conditional payments for non-group health plans? We have some thoughts and tips that will help you better manage this Medicare Secondary Payer compliance risk.

What is a conditional payment? Medicare will often pay for any or all Medicare-covered medical expenses, even when a primary payer exists, to ensure that a Medicare beneficiary receives timely access to needed care. Later, at the time of settlement, judgment, or award, Medicare will seek to recover all payments made, thus the term “conditional” payment. Medicare only pays “conditionally” and has a statutory right to recover those funds. These conditional payments include Medicare Part A (inpatient hospital services), Medicare Part B (outpatient services), Medicare Part C, otherwise known as Medicare Advantage Plans, (these plans are Federally-funded, offering Medicare parts A, B and D through a commercial group health insurance company) and Medicare Part D (prescription drugs).

Conditional payments, for non-group health plans, involve claimants who are Medicare-entitled at the time of settlement. Typically, one third (1/3) of those entitled are due to age 65 and over, and two thirds (2/3) are entitled due to a physical and/or mental disability resulting from an accident or injury.

While it may seem that conditional payment information should reasonably be obtained via MMSEA Section 111 reporting, both the CMS query response file and the quarterly claim response file do not offer eligibility information pertaining to Medicare Advantage Plans (MAPs) or Medicare Part D prescription drugs.

As a non-group health plan, it is important to provide accuracy in the MMSEA section 111 quarterly claim input file, particularly the compensable diagnosis codes that are the responsibility of the primary payer. There are some codes that Medicare will not accept. Working with an experienced MMSEA Section 111 Agent or Medicare Secondary Payer Compliance partner will ensure that all errors are corrected prior to the quarterly file submission to Medicare.

Next, the process is as follows:

  1. Obtain signed HIPAA authorization and social security release forms and a signed proof of representation from the claimant.

  2. Once Medicare benefit eligibility is established, we will notify the Benefits Coordination and Recovery Center (BCRC) that a primary payer exists. We provide the date of injury or illness, primary payer information, as well as the claimant and plaintiff/ applicant attorney name and demographics.

  3. The Medicare beneficiary and representing attorney and the primary payer, (or the authorized agent for the primary payer) are sent a Rights and Responsibilities Letter (RAR) after Medicare has been notified that a primary payer exists.

  4. Within 65 days after the RAR letter is received, a Conditional Payment Notice (CPN) is sent along with a Payment Summary Form (PSF) listing all conditional payments made which are associated with the reported diagnoses.

  5. Upon receipt of the Conditional Payment Notice, review the payment summary form for accuracy. If there is a discrepancy, the primary payer or its authorized agent/vendor should provide a letter of negotiation with evidence to support what the primary payer believes is the accurate conditional payment amount. This negotiation letter must be sent to the CRC within 30 days of the date of the Conditional Payment Notice (CPN). Debtors are allowed a 60-day grace period to repay Medicare from the date of the recovery letter before interest is accrued on the payment. Interest may be calculated using the Federal Register as published by the Secretary of Treasury.

  6. If there is a dispute between the primary payer and the CRC regarding the conditional payment amount, there are only 120 days from the conditional payment notice, to file an appeal.

  7. Otherwise, the conditional payment must be paid to CMS promptly and failure to pay within 90 days, will trigger an “Intent to Refer” letter which states the Department of Treasury will be notified to collect payment. If a full repayment is not received within 60 days of the Intent to Refer letter, the debt is turned over to the Department of Treasury.

  8. If any conditional payment remains delinquent, CMS may recover double damages on their recovery amount, including prevailing interest or even refer the debt to the Department of Justice for legal action.

  9. For conditional payment disputes, there is an appeals process with six levels of appeal that begins with an initial determination to re-determination and reconsideration to a hearing by an administrative law judge, then a review by the Departmental Appeals Board’s Medicare Appeals Council, and finally a Judicial Review. It is difficult to eliminate the conditional payment responsibility based on an argument of hardship, or lack of available funds to pay due to hardship circumstances, but the option is available.

Recently, CMS issued an announcement that it has a new electronic payment process, the new process allows Non-Group Health Plans (NGHP), specifically representative, insurer, or attorney user to log in to the Medicare Secondary Payer Recovery Portal (MSPRP) and make a direct payment to Medicare. A user can access the Claim ID in the lookup tool, then see the full conditional payment balance, including principle and interest, and make either a full or partial payment with the click of a button. Accepted payment methods include a checking or savings account, debit card or PayPal account. Credit cards are not accepted. Payments are processed in 1-3 business days and debited as HHSCMS on the billing statement. The mail-in option is still available, if preferred. The ease and convenience of online payments is now available and serves to demonstrates CMS’ commitment to digitization in MSP. Will we see more opportunities to make direct payments for Medicare Set Asides?

Care Bridge International offers the only complete Medicare Secondary Payer Compliance program using technology-based, data intelligence. We are ready to assist with direct payments to resolve Conditional Payments. Call us today for a free Demo and Consultation!

Click to access our Practical Guide to MSP Compliance and Conditional Payment Checklist

For More Information Contact:

Toll-Free: 888-434-9326 Ext. 103

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