Strategies for Addressing Conditional Payment Claims Asserted by Commercial Repayment Center
Since October 2015, the Commercial Repayment Center (CRC) has been seeking recovery from Responsible Reporting Entities (RREs) when Ongoing Responsibility for Medicals (ORM) is reported under Section 111. The CRC has been increasingly aggressive in pursuing recovery and will often assert claims that are not legitimately owed by RREs. In all likelihood, their recovery efforts will only continue to increase as CMS pays the CRC contractor a contingency fee. In order to assist RREs in addressing conditional payment claims, we have set out a below a list of issues and strategies to consider.
Avoid Missing Deadlines for Disputes and Appeals
Prior to issuing, the CRC is supposed to issue a Conditional Payment Notice (CPN) listing the charges that CRC intends to assert a demand, though it is possible that charges will be added when a demand is issued. There is a 30 day deadline from the date a CPN is issued for responding to the CPN and disputing any charges. If a dispute is not filed, the CRC will automatically issue a demand for reimbursement.
Once a demand is issued, there is a 120 day deadline to file an appeal from the date the demand is received. Under federal regulations, there is a presumption that the demand was received within 5 days of then it was issued. Practically speaking, it can be nearly impossible to convince the CRC that a demand was not received within 5 days. Although the prior CRC contractor years ago would often review late appeals, the current CRC contractor has strictly enforced the 120 day appeal deadline.
Although RREs may be able to request a reopening of a demand after the appeal deadline passes, the decision to approve a request for reopening is within the CRC’s discretion and unfortunately there is no formal appeals process for a request for reopening. Once the 120 day appeal deadline passes, RREs are unable to pursue further appeals unless they can show good cause for a late appeal, which only applies in rare situations.
Missing dispute and appeal deadlines unfortunately gives the CRC an easy opportunity to collect for claims that are not legitimately owed. Once the appeal deadline passes, RREs may be stuck having to pay for claims that the RRE should not owe. The CRC will refer unpaid claims to the Department of Treasury for collection and the Department of Treasury may offset corporate tax refunds to collect. Unfortunately, there is no appeals process for Treasury collections.
Make Sure Correct Address is Reported on Section 111 TIN Reference File
The CRC is supposed to send CPNs and demands to the RRE mailing address reported on the Section 111 TIN Reference File. We have seen some cases in which an incorrect address was reported under Section 111. If this happens, the RRE may not receive a CPN or demand and miss the opportunity to file a dispute and appeal.
Report Accurate Diagnosis Codes and ORM Termination Date
The CRC will seek recovery based on the diagnosis codes reported under Section 111. Additionally, the CRC currently is not supposed to seek recovery for treatment occurring after the ORM termination date. Reporting incorrect diagnosis codes often results in unrelated claims being asserted and forgetting to report the ORM termination date may result in the CRC seeking recovery for claims when the RRE no longer has responsibility for medicals. The CRC generally will defer to information reported under Section 111 in reviewing disputes and appeals, so RREs may be unsuccessful in disputes and appeals if the Section 111 record is not updated to include accurate diagnosis codes and the ORM termination date.
Under Medicare’s proposed regulations for Section 111 penalties, penalties for noncompliance may be assessed if an RRE contradicts information reported under Section 111 in responding to a CPN or demand. CMS has stated that penalties will only be assessed prospectively after any final regulations are issued, so penalties should not be assessed as long as any reporting errors are corrected before the final regulations are issued.
Report Benefits Exhaustion and Submit Case Closure Documents in No-Fault Cases
In no-fault cases, RREs should be certain to report the exhaustion of benefits once policy limits have been exhausted. Otherwise, the CRC may continue to open recovery files. In order to support a request for the CRC to close any open recovery files, RREs should submit a no-fault case closure detail document with a copy of the payment ledger showing that the benefits have been exhausted. If a payment ledger is not available, the CRC will want copies of the cancelled checks for the payments that were issued.
Check for Duplicate Provider Payments in WC and No-Fault Cases
In some cases, providers may bill Medicare in error for treatment that is paid by the RRE. This may result Medicare seeking reimbursement from the RRE even when the RRE has already paid the provider. CPNs and demands should be reviewed to confirm whether the RRE has already issued payment to the provider for the charges asserted. If so, the issue should be raised in a dispute/appeal and a copy of the payment ledger showing the duplicate provider payments should be provided to the CRC.
Present All Relevant Issues and Evidence
In challenging conditional payment claims, all relevant issues and evidence should be raised to provide the best chance for convincing the CRC to withdraw claims. Under federal regulations, RREs generally are unable to present new issues and evidence after the second level in the administrative appeals process.
It is much better to spend the time and effort up front to present a well-argued appeal to the CRC rather than risk having an appeal denied. If an appeal is denied, RREs would have to appeal to the second level appeals contractor, which often is even less willing to remove claims. If a second level appeal is unsuccessful, RREs would have to proceed with an ALJ appeal, which can be a lengthy and costly process.
Appeals Guide from CMS
CMS and the CRC previously published an Appeals Guide for RREs to reference in appealing conditional payment claims. The Guide indicates that one or more of the defenses below may be raised in a conditional payment claim appeal. The Guide is available at https://www.cms.gov/files/document/commercial-repayment-center-non-group-health-plan-applicable-plan-appeal-guide.pdf.
Termination of Ongoing Responsibility for Medicals (ORM) Due to Benefits Exhaustion
Termination of ORM Due to Settlement or Other Claim Resolution
Benefits Denied/ Revoked by Applicable Plan
Duplicate Primary Payment
Termination of ORM Due to Other Policy Terms
If you have any questions or need any assistance with conditional payment claim disputes and appeals, please let us know. Over the years, we have successfully disputed and appealed millions of dollars asserted by the CRC in thousands of cases. Unfortunately, all too often we see cases in which the CRC is overreaching in seeking recovery. We will be happy to assist to help ensure that you do not have to pay any claims that you should not owe.