Recap of Recent CMS Town Hall
Earlier this month, CMS hosted a Town Hall to discuss recovery by the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC) along with issues related to Section 111 reporting.
BCRC vs. CRC
John Albert from CMS began the Town Hall by discussing the division of duties between the BCRC and CRC. The BCRC is supposed to seek recovery from the beneficiary generally when there is a settlement, judgment, or award, and the CRC is supposed to seek recovery from the Responsible Reporting Entity (RRE) when there is Ongoing Responsibility for Medicals (ORM). Mr. Albert reminded listeners to look at which contractor issued correspondence and to be sure to send payment to the appropriate contractor.
Section 111 Reporting Scenarios
Angel Pagan, the EDI Director for the BCRC, discussed Section 111 reporting procedures for a few different scenarios. In the first scenario, the same claim would involve ORM for one injury and TPOC with no ORM for another injury. According to CMS, two add records should be sent – one record for the first injury with ORM marked as “Y” (for yes) and no TPOC information, and another record for the other injury with TPOC information and ORM marked as “N” (for no). Both records may be sent in the same file submission in any order. This scenario is described in the Event Table in Chapter IV of the CMS User Guide.
In the second scenario, ORM ends for one injury due to TPOC and continues for another injury. RREs should send an update record with ORM marked as “Y” and diagnosis codes for the injury for which the RRE continues to have ORM. A second add record should be submitted with the TPOC amount and date, ORM marked as “N” and diagnosis codes for the injury to which TPOC applies. This scenario is consistent with instructions from CMS but is not specifically described in the Event Table in the CMS User Guide.
In the third scenario, ORM ends for one injury and continues for another. RREs should send an update record with ORM marked as “Y” and diagnosis codes for the injury for which the RRE continues to have ORM. This scenario is described in the Event Table in the User Guide.
CRC Recovery Issues
Mileyka Ojeda from the CRC discussed recovery issues and reminded listeners that interest will accrue if conditional payment claims are not resolved within 60 days of a demand, that RREs have 120 days from receipt of the demand to file an appeal, that appeals filed after the 120 day deadline will be dismissed unless “good cause” is shown, and that unpaid debts will be referred to the Department of Treasury at 180 days. For ALJ appeals, CRC requested that parties send the CRC a copy of the ALJ appeal so the CRC can place a hold on the case to avoid a referral to the Department of Treasury.
Question and Answer Session
During the Q&A session, CMS discussed questions that had been submitted to CMS in advance of the Town Hall and then took questions from callers on conditional payment claim recovery and Section 111 reporting. At the outset of the Q&A session CMS stated that they will not be answering any questions about future medicals or Section 111 civil monetary penalties.
In response to a question that was submitted about cases when the claimant refuses to provide his/her SSN, John Albert explained that RREs should document their attempts to obtain the SSN and may have the claimant complete the CMS model form in this situation.
Nicole Griffin from the CRC discussed a question about the CRC’s process for determining which charges are related to reported diagnosis codes. Frequently, CRC will assert claims that have no apparent relationship to the reported diagnosis codes. Ms. Griffin explained that CRC has an automatic process for pulling charges but that CPNs are validated through a human review process.
Jill Jimenez from the CRC addressed a question about obtaining information about unfavorable conditional payment claim disputes. Ms. Jimenez explained that RREs may reach out to the CRC call center and can also send an email to email@example.com.
In response to a question about viewing correspondence on the Medicare Secondary Payer Recovery Portal (MSPRP), Angel Pagan explained that the process is available through multifactor authentication. MSPRP users will have to select the multifactor authentication process when logging in.
Mileyka Ojeda from the CRC discussed a question asking why new charges are sometimes added in response to conditional payment claim disputes. Ms. Ojeda explained that the CRC’s system will continue to search for charges until ORM termination is reported and that the CRC may open multiple recovery files as new charges are found.
A question was also addressed about whether the CRC seeks reimbursement for out of pocket expenses paid to the claimant in no-fault cases. It was explained that parties should provide CMS with an outline of what the expenses were used for in order to support an argument that benefits were properly exhausted.
A question was discussed about differences in conditional payment and demand amounts. It was explained that the amount is subject to change until a demand is issued. Listeners were reminded of the process for obtaining a final conditional payment amount prior to settlement, which is available in certain cases when 120 days’ notice of anticipated settlement is provided to CMS, subject to a very strict process and time limitations. This process is available in liability cases but is not available in workers’ compensation cases when ORM has not terminated.
If you have any questions about the topics discussed in the Town Hall, please let us know. We will be happy to help.