cms

By Tyler Moore Kostal

Historically, the Benefits Coordination and Recovery Center (“BCRC”) arm of the Centers for Medicare & Medicaid Services (“CMS”) collected Medicare’s conditional payments.  While the BCRC continues to address Medicare’s reimbursement rights with Medicare beneficiaries, in late 2015 the CMS’s Commercial Repayment Center (“CRC”) took over responsibility for seeking reimbursement directly from Applicable Plans.  Applicable Plans include liability insurers, self-insured entities, no-fault insurers, and workers’ compensation entities.  If you receive correspondence from the CRC, you must act quickly.

The CRC issues three types of correspondence:

  1. Conditional Payment Letter (“CPL”)
    • A CPL is issued if a beneficiary reports a pending case where an Applicable Plan may have primary payment responsibility, before the Applicable Plan submits a Section 111 report.  There is no time frame for a response, but the Applicable Plan is encouraged to respond expeditiously in certain situations.
  2. Conditional Payment Notice (“CPN”)
    • A CPN is issued when the Applicable Plan notifies CMS that it has primary payment responsibility (or submits a Section 111 report) and Medicare has made conditional payments.  An Applicable Plan has 30 days from the date on the CPN to challenge the claims in the CPN.  If not disputed within 30 days, a demand letter will be issued requiring payment, and interest will be assessed.
  3. Demand Letter
    • Demand letters seek payment within 60 days.  Applicable Plans have 120 days from receipt of a demand to file an appeal.  Receipt is presumed to be five (5) calendar days from the date of the demand letter absent evidence to the contrary.

To date, the CRC has focused the majority of its collection efforts on Group Health Plans.  However, CMS’s annual year-end fiscal report indicates that in 2016, the CRC workload will expand to include the recovery of certain Non-Group Health Plan conditional payments where an Applicable Plan had or has primary payment responsibility.

Additional information on the CRC and the recovery and appeals process is provided on the CMS website:

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The information posted to this blog article is provided for informational purposes only.

Information contained herein is not intended as nor does it constitute legal or professional advice, nor is it an endorsement of any source cited or information provided. Information is subject to change. The applicability of information may vary with case facts and legal updates. Further, the information in this blog is only a summary of many of the relevant provisions of the MSP, Section 111 and related case law. This blog article does not encompass every aspect of these provisions and should not be your only reference for determining Medicare compliance. By way of example only, the CMS issues routine Alerts and updates to its User Guide. Kean Miller will not update this blog article every time there is a new User Guide, Alert and/or a new or revised regulation.

The analysis, conclusions and/or opinions expressed in this article are exclusively those of the author and do not represent the opinions or position of any Kean Miller client.