Author Archives: Settlement Solutions

CMS Releases NGHP Section 111 User Guide v5.3

CMS has released an updated NGHP User Guide, version number 5.3. The updates address the new Medicare Beneficiary Identifier (MBI) initiative in the Introduction, Overview and Appendices chapters.

As required by the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, CMS will be discontinuing all Social Security Number (SSN) based Medicare identifiers and distribute new 11-byte Medicare Beneficiary Identifier (MBI) cards by April 2019. CMS has exempted all Medicare Secondary Payer (MSP) processes from exclusive use of the MBI. Non-Group Health Plan RREs are permitted to continue to report for Section 111 mandatory insurer reporting using: full SSN, Health Insurance Claim Number (HICN), or MBI. Please note, all fields formerly labeled as “HICN” have been relabeled as “Medicare ID” and CMS will be able to accept either a HICN or the new MBI.

Following is a summary of updates appearing in this release:

The Medicare Identifier on Section 111 Response Files

The most current Medicare ID (HICN or MBI) will be returned in the Section 111 response files in the “Medicare ID” field. Consequently, if an RRE submits information with an HICN and the Medicare beneficiary has received their MBI, the MBI will be returned. Otherwise, the most current HICN will be returned. RREs may submit subsequent Section 111 information for this Medicare beneficiary using either the HICN or MBI.

Medicare Identifier on Outgoing Correspondence

As part of the New Medicare Card Project changes, all correspondence from the Benefits Coordination and Recovery Center and Commercial Repayment Center will use the Medicare identifier most recently provided when creating or updating a MSP record. Therefore, if the most recent information received used an HICN, all subsequent issued correspondence will be generated with the HICN as the Medicare ID. If the most recent information received used an MBI, all subsequent issued correspondence will use the MBI as the Medicare ID.

Direct Data Entry (DDE) Users: Claim Searches

Either the MBI or the HICN can be used in the Medicare ID field when searching for claims on the Claim Listing page. All claims that match will display regardless of the Medicare Identifier used to establish the claim.

Retiree Drug Subsidy (RDS) Unsolicited Response Files

RDS Unsolicited Response Files will contain the HICN or MBI in the “Medicare ID” field, as sent by the RDS system (applicable for Group Health Plans only).

General Updates

RREs can use a SSN to query the Health Eligibility Wrapper (HEW) 270/271 query process. The most current Medicare identifier, either HICN or MBI will be returned in the “Medicare ID” field.

The contact protocol for the Section 111 data exchange escalation process (see Section 8.2).

The ICD-10 exclusions for 2018 (see Chapter 5 Appendices, Appendix I and Appendix J).

CMS will continue to review reporting requirements and post any applicable updates in the form of revisions to Alerts and the user guide as necessary.

A consolidated PDF file of all these updates is available upon request. Please email JustRegister@optum.com if you would like to receive a consolidated, searchable file.

New Commercial Repayment Center (CRC) contract awarded

Performant Financial Corporation announced on October 5, 2017, they were awarded the Medicare Secondary Payer Commercial Repayment Center (CRC) contract by the Centers for Medicare & Medicaid Services (CMS). Performant will succeed CGI Federal, the current contractor.

Performant is a leader in the identification and recovery of improper payments in the health care, government and student loan industries; Further, it will be Performant’s responsibility to identify and recover payments in situations where Medicare should not be the primary payer of health care claims when a beneficiary has other forms of insurance coverage, such as employer Group Health Plan or other certain other payers.

Congratulations, Performant, and we look forward to working with you.

CMS Keeps $1,000 Mandatory Reporting and Conditional Payment Threshold

Rafael Gonzalez, Esq.
Vice President, Strategic Solutions

As per the SMART Act, “reimbursement of conditional payments and mandatory reporting shall not apply with respect to any settlement, judgment, award, or other payment by an applicable plan arising from liability insurance (including self-insurance) and from alleged physical trauma-based incidents (excluding alleged ingestion, implantation, or exposure cases) constituting a total payment obligation to a claimant of not more than the single threshold amount calculated by the Secretary for the year involved.” As a result, since 2013, “the annual single threshold amount for a year shall be set such that the estimated amount shall equal the estimated cost of collection incurred by the United States (including payments made to contractors) for a conditional payment arising from liability insurance (including self-insurance).” Consequently, on October 19, 2015, CMS published its “Computation of Annual Liability Insurance (Including Self-Insurance) Settlement Recovery Threshold,” and its Alert on “2015 Recovery Threshold for Certain Liability Settlements, Judgments, Awards or Other Payments.”

Medicare Secondary Payer Act

The publications indicate that “the Medicare Secondary Payer (MSP) provisions, found at section 1862(b) of the Social Security Act, prohibit Medicare from making payment where payment has been made or can reasonably be expected to be made by a primary plan. If payment has not been made, or cannot reasonably be expected to be made promptly by a primary plan, Medicare may pay conditionally, with the expectation that the conditional payments would be reimbursed, once primary payment responsibility is demonstrated.”

Settlement, Judgment, Award, or Other Payment

“In liability insurance (which always includes self-insurance) situations, the primary plan has demonstrated primary payment responsibility when a settlement, judgment, award, or other payment (settlement) occurs. Accordingly, Medicare is obligated by statute to recover conditional payments it made for medical care related to the settlement. Medicare’s recovery is limited to the amount of the settlement less any attorney fees or costs the beneficiary incurred to obtain the settlement.”

Mandatory Insurer Reporting

The announcements also indicate that “Medicare beneficiaries, their attorneys, and applicable plans report settlements to Medicare. Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) requires that an applicable plan making an insurance or workers’ compensation settlement payment report that payment to Medicare. This reporting is required so Medicare is able to determine if it made any conditional payments related to that settlement. Once reported, Medicare calculates its conditional payment amount, reduces that amount for attorney fees and costs, and issues a demand letter requiring reimbursement.”

Associated Medicare Costs

The reports also state that “Medicare incurs costs to perform these activities. These costs include compiling related claims, calculating conditional payments, applying reductions, sending demands, providing customer service, etc. In addition to CMS’ costs associated with pursuing recovery, Medicare does not usually recover the full amount of the conditional payments. For example, there may be reductions to the demand to account for procurement costs (attorney fees and costs) or for full or partial waiver of recovery if certain criteria are met. Implementing a threshold allows CMS to use its resources wisely.”

Threshold for Physical Trauma Liability Insurance Settlements

The analysis shows that resulting from amendments to the MSP Act in 2012, “in 2013, as an annual requirement of section 202 of the Act, CMS reviewed all of the costs related to collecting data and determining the amount of Medicare’s recovery claim. As a result of this analysis, CMS calculated a revised threshold for physical trauma-based liability insurance settlements. Effective January 1, 2014, CMS established a single threshold for these cases, where settlements of $1000 or less do not need to be reported and Medicare’s conditional payment amount related to these cases did not need to be repaid. In 2014, CMS reviewed current costs related to collecting data and determining the amount of Medicare’s recovery claim. For 2015, CMS has determined that it will maintain the current single threshold for these cases, where settlements of $1000 or less do not need to be reported and Medicare’s conditional payment amount related to these cases does not need to be repaid.”

Average Cost of Collection for NGHP Cases

The publications provide that “CMS estimated the average cost of collection for Non-Group Health Plan (NGHP) cases as approximately $420 a case. This cost of collection was based on the amount paid (invoices) to our Benefits Coordination and Recovery Contractors for work related to identifying and recovering NGHP conditional payments (this data includes liability insurance, no-fault insurance and workers’ compensation). The data used were for the fiscal year 2014. The total dollar amount paid to our contractors was divided by the number of final NGHP demand letters issued in 2014. The average cost of collection per NGHP case was calculated to be approximately $420.”

Based on Cost, Configuration of Threshold

The information suggests that “CMS then examined the amounts demanded for liability insurance cases for FY 2014. Different settlement amount ranges were examined. The settlement amount range that had the demand amount closest to the $420 cost of collection was for settlements above $750 and less than or equal to $1000. The average demand amount for this range of settlements was $436. Based on this information, CMS determined it should maintain the threshold of $1000, so that physical trauma-based liability insurance (including self-insurance) settlements of $1000 or less do not need to be reported and Medicare’s conditional payment amount for these settlements does not need to be repaid.”

Threshold Remains Same

As required by section 1862(b)(9) of the Act, “CMS will maintain the single threshold for physical trauma-based liability insurance settlements of $1000 or less. Therefore, Medicare will not require reporting and Medicare will not assert a recovery claim against physical trauma-based liability insurance settlements that are $1000 or less. This threshold does not apply to settlements for alleged ingestion, implantation or exposure cases.” Information on the methodology used to determine the threshold is provided at https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Beneficiary-Services/Downloads/Computation-of-Annual-Liability-Insurance-Including-Self-Insurance-Settlement-Recovery-Threshold-2015.pdf.

As always, Helios Settlement Solutions will continue to keep you updated on this and all other Medicare Secondary Payer compliance matters. Should you have any questions or if we can be of any help, please do not hesitate to contact us at 888.672.7674, or at contactus@helioscomp.com.

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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.

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