Reminder: Changes to Conditional Payment Claim Recovery Process
October 5, 2015
As we previously reported, beginning October 5, 2015, the Commercial Repayment Center (CRC) will handle the recovery of conditional payment claims when CMS is pursuing reimbursement directly from the primary payer. The Benefits Coordination and Recovery Center (BCRC) will still handle the recovery process when CMS is pursuing reimbursement from the beneficiary.
CMS has indicated that the CRC may pursue recovery from the RRE when ORM has been reported under Section 111 or when the RRE or their representative has otherwise notified CMS that the RRE is responsible for paying for a Medicare beneficiary's treatment. In addition, CMS has indicated that the BCRC will typically pursue recovery from the beneficiary first when CMS is pursuing recovery based on a settlement, judgment, or award. However, if the conditional payment claims remain unresolved by the beneficiary, the CRC could pursue recovery from the primary payer.
In general, liability cases should remain unaffected by the new process since they very rarely involve ORM. However, RREs may start receiving conditional payment notices (CPNs) and demands prior to a settlement, judgment, or award in workers' compensation and no-fault cases involving ORM.
It is critical for RREs to respond to CPNs and demands in a timely manner. A CPN is not a request for reimbursement. However, a CPN provides a 30 day timeframe to file a dispute before a demand is issued. Once a demand is issued, an appeal must be filed within 120 days of receipt of the demand, and CMS assumes receipt of the demand within 5 days under federal regulations.
If an RRE's initial appeal is unsuccessful, the RRE or their representative may continue to appeal conditional payment claims through an administrative appeals process that includes 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.
If you have any questions regarding the changes to the recovery process, please do not hesitate to let us know.