On September 17, 2015, CMS held a webinar to discuss the new role of the Commercial Repayment Center (CRC) in the NGHP recovery process. Beginning October 5, 2015, the CRC will handle the recovery of conditional payment claims when Medicare is pursuing reimbursement directly from the primary payer. CMS indicated in the webinar that the CRC will primarily pursue recovery from the primary payer in cases in which ORM has been reported under Section 111 or the primary payer has otherwise notified CMS of their responsibility to pay ongoing medical expenses. CMS stated that, generally, the Benefits Coordination and Recovery Center (BCRC) will pursue recovery from the claimant first when CMS is pursing recovery based on a settlement, judgment, or award.
Given the CRC’s new role, beginning October 5, 2015, RREs may start receiving requests for reimbursement prior to a settlement, judgment, or award if the RRE has ORM. Any recovery correspondence will be sent to the address for the RRE reported under Section 111. If the CRC intends to seek recovery from an RRE based on ORM, the CRC should first issue a Conditional Payment Notice (CPN). After a CPN is issued, parties have 30 days to file a dispute. If no dispute is filed, the CRC should then issue a demand. If the demand is not paid within 60 days, interest will be assessed and will continue to accrue every 30 days. Parties have 120 days to file an appeal following receipt of a demand, and CMS assumes receipt of the demand within 5 days pursuant to federal regulations.
As we previously reported, RREs and their representatives may now go through an administrative appeals process to challenge conditional payment claims when CMS is pursuing recovery from the RRE. The appeals process includes an initial appeal, a reconsideration by a Medicare Qualified Independent Contractor, a hearing with an Administrative Law Judge, and review by the Medicare Appeals Council. After all appeals have been exhausted, the RRE may then seek judicial review. However, RREs that fail to appeal claims through the administrative appeals process within the appropriate time frames will lose the right to seek judicial review or otherwise appeal the amount owed.
Given the deadlines for filing disputes, appeals, and issuing payment, it is critically important for RREs to process and respond to CPNs and demands in a timely manner. If you receive any recovery correspondence from the CRC and have any questions or would like any assistance, please do not hesitate to contact us.