CMS Announces Conditional Payment Portal Process Functionality Details

Pills and DollarsAs Medicare Secondary Payer stakeholders get ready to start resolving conditional payments through CMS’ portal beginning January 1, 2016, on December 21, 2015, CMS published an announcement on its website regarding Modification of the Medicare Secondary Payer Recovery Portal (MSPRP) for Inclusion of Final Conditional Payment (CP) Process Functionality.

As part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP was modified to include Final CP process functionality.  This new functionality “provides authorized MSPRP users with the option to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement, ensure that relatedness disputes are addressed within 11 business days of receipt of dispute documentation, request a Final Conditional Payment Amount, and obtain a time and date stamped final conditional payment summary document before reaching settlement.”  Once the Final Conditional Payment has been calculated, this amount will not change as long as “the case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.”

As in all previous communications from CMS on this matter, the December 21, 2015 announcement reiterates that “a request for a Final Conditional Payment Amount can only be done once per case.  If the case is not settled with 3 days and/or the settlement information is not submitted through the MSPRP within 30 calendar days, the Final CP process will be voided.”  At that time new claims may be added to the case and the CP amount will be modified accordingly.  And it what seems to be a new component of this process, the announcement indicates that “any subsequent disputes will not be held to the 11 day resolution timeframes.”

The announcement includes an important note, indicating that “an insurer and their authorized representatives can initiate the Final CP process on their insurer-debtor case as long as a settlement is pending on the case and no outstanding Ongoing Responsibility for Medicals (ORM) exists.”  However, new to the process is the indication that “once the Final CP process has been started on an insurer-debtor case, the insurer-debtor case will be closed and the debt will be transferred to a new case where the beneficiary is the identified debtor.” As a result, the insurer and their authorized representatives “will not be able to work the new beneficiary-debtor case or receive copies of any recovery-related correspondence related to the new beneficiary-debtor case until they obtain and submit an authorization signed by the beneficiary.”

As always, Helios Settlement Solutions will continue to track changes made to the Medicare Secondary Payer Recovery Portal and Final Conditional Payment Process Functionality. In addition, our conditional payment resolution team made up of attorneys, nurses, pharmacists, and claims specialists with years of experience handling resolution of conditional payments will continue to report how such changes affect your claims currently and their potential resolution. For more information about Helios conditional payment resolution services, please do not hesitate to contact us at 888.672.7674, or at contactus@helioscomp.com.

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About Rafael Gonzalez

As vice president of strategic solutions, Rafael Gonzalez serves as a thought leader on all aspects of Medicare and Medicaid compliance issues, including mandatory insurer reporting, conditional payments resolution, Medicare set aside allocations, CMS approval, and professional administration of Medicare set asides and special needs trusts. Prior to joining Helios, over the last 30 years, Rafael served as director of Medicare & Medicaid compliance and post settlement administration for Gould & Lamb in Bradenton, Florida. Before that, he served as chief executive officer for the Center for Lien Resolution, the Center for Medicare Set Aside Administration and the Center for Special Trusts Administration in Clearwater, Florida. Prior to that, he served as corporate counsel for FCCI Insurance, a workers’ compensation/property casualty insurance company in Sarasota, Florida. And before that, he practiced social security disability, workers’ compensation, longshore and personal injury law in Tampa, Florida. Rafael Gonzalez received his Bachelor of Science degree from the University of Florida and his Jurisprudence Doctorate degree from the Florida State University.

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