As Promised, Conditional Payments Resolution via Web Portal to Start 1/1/16

Rafael Gonzalez, Esq.
Vice President, Strategic Solutions

Introduction

092815_1655_NewProcessf1.gifOn November 9, 2015, CMS published an update on the much anticipated Medicare Secondary Payer Recovery Portal (MSPRP) Conditional Payment process. The entire Medicare Secondary Payer (MSP) community has been waiting on this since September 20, 2013, when the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) published CMS-6054-IFC, RIN 0938-AR90 as an interim final rule on obtaining final MSP conditional payment amounts via web portal.

The 9/20/13 interim final rule specified the process and timeline for expanding CMS’ web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act). The interim final rule specified a timeline for developing a multifactor authentication solution to securely permit authorized users other than the beneficiary to access CMS’ conditional payment amounts and claims detail information via the CMS web portal.

The interim final rule also indicated CMS’ intent to add functionality to the web portal so as to permit users to notify CMS that the specified case was approaching settlement; obtain time and date stamped final conditional payment summary forms and amounts before reaching settlement, and ensure that relatedness disputes and any other discrepancies were addressed within 11 business days of receipt of dispute documentation.

Although it has taken a while, having developed and recently announcing a multifactor authentication solution earlier in 2015 to securely permit authorized users other than the beneficiary to access CMS’ conditional payment amounts and claims detail information via the web portal, on November 9, 2015, CMS published an update on the Medicare Secondary Payer Recovery Portal modification for inclusion of Final Conditional Payment (CP) process functionality.

CMS’ November 9, 2015 Announcement

As expected, the announcement indicated that “pursuant to the SMART Act, the MSPRP will be modified to include Final CP process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.”

The 11/9/15 announcement indicated that “when the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute.  Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP.”  Once calculated, this amount will remain the “Final Conditional Payment Amount as long as the case is settled within 3 calendar days of requesting the Final CP amount, and settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final CP amount.”

CMS’ September 20, 2013 Interim Final Rule

The 9/20/13 interim final rule produced 42 CFR Section 411.39, specifically addressing automobile and liability insurance (including self-insurance), no-fault insurance, and workers’ compensation: final conditional payment amounts via web portal. The interim rule provided beneficiaries access to his or her MSP conditional payment information via the MSPRP, provided that “the beneficiary created an account to access his or her Medicare information through the CMS website, and the beneficiary provided initial notice of a pending liability insurance (including self-insurance), no-fault insurance, or workers’ compensation settlement, judgment, award, or other payment to the appropriate Medicare contractor at least 185 days before the anticipated date of settlement, judgment, award, or other payment.”

The interim final rule also provided a beneficiary’s attorney or other representative, or applicable plan’s access on or before December 31, 2015, and after January 1, 2016. On or before December 31, 2015, a beneficiary’s attorney or other representative or an applicable plan, would be able to view total MSP conditional payment amounts and masked claim-specific information, including dates of services, provider names, and diagnosis codes, so long as “the authorized attorney or other representative or authorized applicable plan had properly registered to access the web portal, and the attorney or other representative or applicable plan obtained proper authorization from the beneficiary and submitted it to the appropriate Medicare contractor in the form of either proof of representation or consent to release in order to access the beneficiary’s case specific information.” Once such authorization was obtained, “a beneficiary’s attorney or other representative or an applicable plan could dispute claims, upload settlement information, and receive a final CP demand through the MSPRP.”

The interim final rule also indicated that “on or after January 1, 2016, a beneficiary’s attorney or other representative or an applicable plan could access conditional payment information via the MSPRP using the multifactor authentication processes, dispute claims and upload settlement information via the web portal, and obtain a final conditional payment amount.”

The Medicare Secondary Payer Recovery Portal Resolution Process

As indicated by the 9/20/13 interim final rule, the MSPRP process is as follows:

  • A beneficiary’s attorney or other representative or an applicable plan must properly register to access the web portal, and obtain proper authorization from the beneficiary and submit it to the appropriate Medicare contractor in the form of either consent to release (in order to access the beneficiary’s case specific information) or proof or representation (in order to dispute claims, upload settlement information, and receive a final CP demand).
  • A beneficiary’s attorney or other representative or an applicable plan must provide initial notice of a pending liability insurance (including self-insurance), no-fault insurance, and workers’ compensation settlement, judgment, award, or other payment to the appropriate Medicare contractor at least 185 days before the anticipated date of settlement, judgment, award, or other payment.
  • The Medicare contractor compiles and posts claims for which Medicare has paid conditionally that are related to the pending settlement, judgment, award, or other payment within 65 days of receiving the initial notice of the pending settlement, judgment, award, or other payment.
  • Beginning any time after CMS posts its initial claims compilation, and up to 120 days before the anticipated date of a settlement, judgment, award, or other payment, the beneficiary, or his or her attorney, or other representative or applicable plan may notify CMS, once and only once, via the web portal, that a settlement, judgment, award or other payment is expected to occur within 120 days or less from the date of notification.
  • The beneficiary, or his or her attorney, or other representative or applicable plan may address discrepancies by disputing a claim, once and only once, if he or she believes that the claim included in the most up-to-date conditional payment summary form is unrelated to the pending liability insurance (including self-insurance), no-fault insurance, or workers’ compensation settlement, judgment, award, or other payment.
  • Disputes submitted through the web portal are to be resolved within 11 business days of receipt of the dispute and any required supporting documentation.
  • When any disputes have been fully resolved and the beneficiary, or his or her attorney, or other representative or applicable plan has executed and obtained confirmation of the completion of a final claims refresh, then the beneficiary, or his or her attorney or other representative, or applicable plan may download or otherwise request a time and date stamped conditional payment summary form through the web portal. If the download or request is within 3 days of the date of settlement, judgment, award or other payment, that conditional payment summary form will constitute Medicare’s final conditional payment amount.
  • Within 30 days of securing a settlement, judgment, award, or other payment, the beneficiary, or his or her attorney or other representative or applicable plan, must submit through the web portal settlement documentation which indicates the date of settlement, judgment, award, or other payment, including the total settlement amount, the attorney fee amount or percentage, as well as any additional costs borne by the beneficiary to obtain his or her settlement, judgment, award, or other payment.
  • If settlement information is not provided within 90 days of securing the settlement, the final conditional payment amount obtained through the web portal is void.
  • Once settlement, judgment, award, or other payment information is received, CMS applies a pro rata procurement reduction to the final conditional payment amount in accordance with 42 CFR Section 411.37 and issues a final MSP recovery demand letter.

Helios Settlement Solutions has been preparing for the implementation of the SMART Act since becoming law in January 2013. As a result, Helios’ Conditional Payment Resolution team is ready to assist current and potential clients with implementation of CMS’ 9/20/13 interim final rule by incorporating the MSPRP resolution process effective January 1, 2016. Should you have any questions pertaining to this new procedure, or if we can be of any assistance regarding this expedited web portal process, please do not hesitate to contact us at 888.672.7674, or at contactus@helioscomp.com.

helios-logo

Leave a Reply