Conditional Payment Case Study and This Week’s Happenings

Conditional Payments are one of those less common, but required claim tasks which must occur prior to settling any claim involving a Medicare Beneficiary. The process can be messy and cumbersome depending on factors related to how the primary non group health payer reported the claim to Medicare, based upon the facts of the case itself or based upon Medicare's own dual process, whereby Conditional Payment Recovery can occur either on the Commercial payer side or Medicare Beneficiary side of the process.


Conditional Payment Research and Negotiation is a service offered at Care Bridge International either on a stand-alone basis or included as part of our Medicare Set Aside referral process. We have a lot of success in this domain of Medicare Secondary Payer compliance. Today, we want to share an actual case study that represents the type of results that we are able to secure for our clients every single day.


CASE STUDY:


Care Bridge International received a Medicare Conditional Payment demand from Medicare’s Commercial Repayment Center (CRC), involving a denied/ disputed low back injury, in the amount of $171,693.71. Our team of experts wrote a 48-page letter to the CRC successfully negotiating the charges, and the CRC accepted our arguments.

Dear CRC:


This letter is written in response to the conditional payment notice received on 08/04/2020. The CRC identified possible conditional payments in the amount of $171,693.71 related to a Workers’ Compensation Claim.


Please note the diagnoses involving the Workers’ compensation claim, denied in its entirety, are as follows:


Low Back Pain

Intervertebral disc displacement, lumbar region

Thoracic thoracolumbar and lumbosacral intervertebral disc disorder

Sciatica

Panniculitis affecting region of neck have, back, sacral and sacrococcygeal region.

Sprain of ligaments of lumbar spine


The conditional payments identified as being related to the WC claim are: $0 Total due is: $0.


Next, we received an Intent to Refer to Treasury (ITR) notice for different/ separate charges in the amount of $86,609.83 involving this same claim. Our team of experts filed a second negotiation, also returned fully favorable.

In summary, we saved our client a total of $258,303.54 on a single claim involving two separate conditional payment demands from Medicare. That is an EXCELLENT Result and we celebrate these results because we are passionate about our role in getting BIG WINS for our customers.



This Week's Happenings!


Join Christopher Frankland, Chief Innovation Officer, Care Bridge International, March 9, 2021.