After Transition to Commercial Recovery Center, Business as Usual? Or Are Changes Coming?

Insurance LawPost by Rafael Gonzalez, Esq.
Vice President, Strategic Solutions, Helios

On July 29, 2015, the Centers for Medicare and Medicaid Services, Office of Financial Management, Financial Services Group (CMS) announced that on Tuesday, August 25, 2015 at 2:00 PM EST, it will hold a webinar on the new role of the Commercial Repayment Center (CRC) in the Non-Group Health Plan (NGHP) conditional payment recovery process. To register, please visit https://event.webcasts.com/starthere.jsp?ei=1071085.

As CMS previously informed on July 1, 2015, the July 29, 2015 announcement again indicates that “as part of CMS’ continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, CMS will be transitioning a portion of the NGHP recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its CRC.” The announcement makes it clear that “effective October 2015, the CRC will assume responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity as the identified debtor.”

Once the transition is complete to the CRC, will it be business as usual? Or will things change? Will CMS begin pursuing recovery directly from liability insurers (including self-insured entities), no-fault insurers or workers’ compensation (WC) entities as the identified debtor more frequently? Perhaps on a consistent manner? Will CMS also begin to pursue pre-settlement conditional payments directly from NGHPs on cases where no-fault  insurers or workers’ compensation entities have reported to CMS that they have Ongoing Responsibility for Medicals (ORM) for specific care?

We do not know the answers to these questions, but when coupled with the July 1, 2015 announcement that effective January 1, 2016, CMS will add an additional limitation to Medicare claims payments where insurers or workers’ compensation entities have reported to CMS that they have ORM for specific care, it is becoming increasingly clear that CMS’ claims processing contractors will use Mandatory Insurer Reporting (MIR) information provided by the insurer or workers’ compensation entity to determine whether Medicare is able to make payment for those claims. This not only means insurers and workers’ compensation entities that notify Medicare that they have ORM are strongly encouraged to report accurate ICD-9 or ICD-10 codes, since Medicare’s claims processing contractors will use this information to pay accordingly, but may also signal the start of an aggressive attempt by CMS to seek reimbursement of conditional payments directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity as the identified debtor.

In addition, as has been previously mentioned at several NGHP Town Hall Teleconferences over the last three years, because the transition to CRC only includes those cases where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly, meaning beneficiaries and their attorneys will continue to work with the BCRC where CMS is pursuing recovery from the beneficiary post settlement, this may also signal the beginning of CMS’ pre-settlement conditional payment recovery attempts from liability insurers, no-fault insurers, and WC entities directly. Considering the thousands of claims where no-fault insurers or workers’ compensation entities have reported to CMS that they have ORM for specific care, and the millions of dollars in conditional payments made by Medicare in such claims that have never been reimbursed, having a new contractor like the CRC to deal specifically with liability insurers, no-fault insurers, and WC entities directly may mean the beginning of such efforts.

Helios Settlement Solutions is prepared to assist clients dealing and communicating with the Commercial Recovery Center. As we have been doing for years, our Conditional Payments Resolution team is ready to continue to help clients with cases where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly.  As always, we will continue to monitor these issues and be sure to report on any changes, including items discussed in the August 25, 2015 webinar.

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