CMS Webinar Expounds on Commercial Repayment Center Procedures


On Tuesday, August 23rd, 2015 CMS held a webinar further explaining the new  policies and procedures for conditional payment recovery through the  Commercial Repayment Center (CRC) and the Benefits Coordination and Recovery  Center (BCRC). On July 1, 2015, CMS first announced that it would be transitioning  a portion of the NGHP recovery workload from the Benefits Coordination &  Recovery Center (BCRC) to the CRC. CMS explained that the transition was part of  a continuing effort to improve the conditional payment recovery and its accuracy  in Medicare Secondary Payer (MSP) situations.

Effective October 5, 2015, the CRC assumes responsibility for the recovery of  conditional payments when CMS pursues recovery directly from a liability insurer  (including a self-insured entity), no-fault insurer or workers’ compensation (WC)  entity (Applicable Plan) as the identified debtor. In situations where the identified  debtor is the beneficiary, the BCRC will continue to be responsible for those cases.

As indicated in the July announcement, Section 111 of the Medicare, Medicaid  and SCHIP Extension Act (MMSEA) reporting and the broader requirements of the  Medicare Secondary Payer will trigger CMS recovery action. The MSP Act, in 42  U.S.C. 1395y(b) and 42 C.F.R. Part 411, preclude Medicare from paying for a  beneficiary’s medical expenses when payment “has been made or reasonably can  be expected to be made under a workers’ compensation plan, an automobile or  liability policy or plan (including a self-insurance plan), or under no-fault  insurance.” Accordingly, once payment has been made on behalf of a beneficiary,  reimbursement rights ripen. 

Until the July announcement, CMS had not sought recovery from any entity until a  settlement or judgment had been obtained. However, CMS has now begun  recovery action based upon the existence of Ongoing Responsibility for Medical  (ORM) that is reported electronically through Section 111 Reporting. In cases  where the ORM indicator is populated, CMS will begin recovery either as against a  beneficiary or Applicable Plan. As noted, if against an Applicable Plan, the action is  instituted by and through the CRC whereas the BCRC will pursue a beneficiary. All  cases instituted and pursued by the BCRC prior to October 5, 2015 will remain  with the BCRC. The CRC will be responsible for recovery actions against Applicable  Plans instituted after that date.

According to CMS, the Section 111 report on a claim will cause the CRC to issue a  Conditional Payment Notice (CPN) to the Applicable Plan. The Notice will include a  Statement of Reimbursement (SOR) itemizing charges deemed related to the  injury. If not disputed within 30 days, a Demand Letter will follow requiring  payment by the Applicable Plan. Applicable Plans should be prepared to expect  Demand Letters as early as October 25, 2015. Additionally, CMS will assess  interest on Demand Letter amounts and will no longer wait 60 days, as had been  their previous procedure. No appeal can be made until a Final Demand is received.

As with the previous announcement, CMS reiterated that Applicable Plans may  designate a Recovery Agent to address recovery issues. Section 111 allows a  Responsible Reporting Entity to designate a Recovery Agent for the recovery  process. However, updated authorizations to act on behalf of the Applicable Plan  will still be required when the Recovery Agent will be responsible for dealing with  the CRC. 

Based upon the announcement and the webinar, it appears that CMS has taken an  aggressive stance on conditional payment recoveries. Rather than wait for the  parties to settle an injury case, CMS will assert its priority rights to recovery. Much  like the relatively recent move by CMS to automatically generate conditional  payment recovery action based upon the report of a settlement, judgment or  award through Section 111, the reporting of the existence of ORM will now  generate recovery activity which, presumably, will be automatically generated as  well. With the transition from International Classification of Disease (ICD) 9 coding  to ICD-10 coding set to occur on October 1, 2015, it is hoped that the more  comprehensive and accurate ICD-10 codes will result in less recovery activity if the  coding is properly utilized. 

The webinar will be replayed again on September 17, 2015 due to some technical  difficulties. Applicable Plans would be well served to attend the rebroadcast and  provide CMS with any questions or concerns not addressed using the CMS inbox.  In the interim, procedures surrounding the reporting of ORM should be reviewed  as well as the timeframes for appeal of Final Demands. Of course, the designation  of a Recovery Agent and updated authorizations for the Agent are critical as is  ensuring a proper methodology for capturing and reporting the correct ICD-10  codes. ECS customers will continue to be updated on operational changes and  procedural changes regarding both MMSEA reporting and Conditional Payment  recovery.