CMS Announces It has Issued more than 33,000 CPLs and CPNs Since October 1, 2015; More Are Coming!

Rafael Gonzalez, Esq.
Vice President, Strategic Solutions, Helios

CMS Stack of PapersAs we have previously informed here, “in October 2015, the Centers for Medicare & Medicaid Services’ (CMS) Commercial Repayment Center (CRC) assumed 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.” On February 9, 2016, the CRC announced it has “issued more than 33,000 Conditional Payment Letters (CPLs) and Conditional Payment Notices (CPNs) since the transition.”  CMS further indicated that it “is aware that many insurers and WC entities are awaiting CPLs, CPNs, or demand letters.” As a result, CMS informed that it “is actively engaged with the CRC to improve responsiveness to requests for conditional payment information and the handling of correspondence.” https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Whats-New/Whats-New.html

Confused About When to Deal with the Benefits Coordination and Recovery Center Instead of the Commercial Repayment Center?

If you are still confused about when to deal with the Benefits Coordination and Recovery Center (BCRC) instead of the CRC, you are not alone. CMS indicates “you should contact the BCRC when Medicare is pursuing recovery from the beneficiary as the identified debtor. CMS pursues recovery from the beneficiary when the applicable plan has not reported ongoing responsibility for medicals (ORM) and has not otherwise notified CMS of primary payment responsibility. Typically this is when the beneficiary obtains a lump sum settlement, judgment, award, or other payment. This situation most frequently occurs with liability insurance, including self-insurance.”

Which means you should be dealing with the CRC if “you are an applicable plan or recovery agent for an applicable plan and you have questions about recovery cases initiated by the CRC.” As previously indicated by CMS, the CRC “pursues recovery directly from an applicable plan as the identified debtor when an applicable plan reports that it has ORM or otherwise notifies CMS of its primary payment responsibility, as the assumption is that the applicable plan’s responsibility is not in dispute. This situation most frequently occurs in no-fault insurance and workers’ compensation.”

Confused About What Prompts BCRC or CRC to Issue a Conditional Payment Notice Versus a Conditional Payment Letter?

If you are still confused about what prompts the BCRC or CRC to issue a CPN versus a CPL, you are definitely not alone. As CMS has previously explained, the CPN and CPL provide the same information regarding conditional payments and allow recipients an opportunity to dispute conditional payments before the demand is issued. However, there are some major differences.

A CPN will be issued by the CRC when “the applicable plan has notified CMS that it has primary payment responsibility for certain care and Medicare has made conditional payments. CMS may be notified of this through MMSEA Section 111 Mandatory Reporting or through a telephone call or written correspondence. In the absence of a dispute filed within the CPN response due date (30 days), the CRC will issue a demand letter automatically. The demand will include conditional payments included in the CPN as well as any additional conditional payments identified after the CPN was issued. It will provide instructions on making payment (within 60 days) or on formally appealing CMS’ determination (within 120 days).”

A CPL will be issued by the CRC when a “beneficiary (or their representative) reports a pending case where an applicable plan may have primary payment responsibility for certain care related to the injury and the MSP occurrence was not otherwise reported by the applicable plan itself (through MMSEA Section 111 reporting or by other means). The applicable plan may dispute conditional payments in the CPL, but unlike the CPN, there is no specific response due date. Therefore, the CPL is not automatically followed by the demand letter; the applicable plan or recovery agent must request it.”

Still Confused? Need Help Sorting all of this Out? Want an Agent to Handle it for You?

As CMS has previously indicated, applicable plans may appoint a recovery agent to work with the CRC and BCRC to resolve conditional payments. Helios Settlement Solutions serves as the recovery agent for several state, regional, and national self-insured, third party administrators, and insurers. We have a dedicated team of attorneys, nurses, pharmacists, claims specialists, and conditional payment specialists ready to assist you and your team. If we can be of any assistance to your organization in dealing with and ultimately resolving CRC or BCRC conditional payments, please 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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