Tag Archives: CMS

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.

CMS Announces NGHP Town Hall Teleconference for July 28, 2015

Post by Frank Fairchok MedicareConnect℠ Senior Manager

Post by
Frank Fairchok
MedicareConnect℠ Senior Manager


CMS has announced a Town Hall Teleconference on Tuesday, July 28, 2015 to provide comments about the upcoming transition of a portion of the Non-Group Health Plan Recovery Workload to the Commercial Repayment Center and to address both policy and technical questions for Section 111 reporting. The details to access the conference are as follows:

  • Date: July 28, 2015
  • Call-in time: 1:00 PM – 2:00 PM Eastern time.
  • Participation is by telephone only on call-in line: (800) 603-1774
  • Pass Code: Section 111

CMS encourages all participants to dial-in 20 minutes before the start of the call due to the high number of expected participants.

Questions will be answered live on the call and participants have the option of submitting the questions prior to the call to PL110-173SEC111-comments@cms.hhs.gov

Helios will participate in the teleconference to ensure our clients have access to the latest information from CMS for the topics discussed.

For more information, please contact Frank Fairchok, Senior Manager of MedicareConnect℠ at Frank.Fairchok@helioscomp.com.

NGHP User Guide 4.7 Released on July 13, 2015

Post by
Frank Fairchok
MedicareConnect℠ Senior Manager

CMS has released an updated User Guide with version number 4.7 on July 13, 2015. This update appears to incorporate alerts previously released only. CMS provides the summary of updates, along with the User Guide chapters impacted, as follows:

  • Change Request 32: Accept and process Recovery Agent information on Section 111 NGHP TIN Reference File (all chapters, predominantly Chapters III, IV, and V).
  • Change Request 15830: The URL for Section 111 was changed (all chapters).
  • Change Request 15931: To prevent false positives in partial SSN searches, the number of additional criteria needed to return a match is increased from three of four to all four (Chapter IV).
  • Change Request 15969: The response file naming convention was changed for NGHP files (Chapter IV).

Helios can provide a consolidated PDF file of all the updated chapters upon request. Please contact us at JustRegister@Helioscomp.com if you would like to receive this consolidated, searchable file.

For more information, please contact Frank Fairchok, Senior Manager of MedicareConnect℠, at Frank.Fairchok@helioscomp.com.

CMS Announces Switch on NGHP Conditional Payment Recovery from BCRC to CRC and Use of ICD-9 and ICD-10 to Determine Payment of Medical Bills

Article by Rafael Gonzalez, Esq. Vice President, Strategic Solutions HELIOS Settlement Solutions

Article by
Rafael Gonzalez, Esq.
Vice President, Strategic Solutions
HELIOS Settlement Solutions

On July 1, 2015, CMS published an announcement on its upcoming transition of Non-Group Health Plan recovery workload from the Benefits Coordination & Recovery Center to the Commercial Repayment Center.

As part of the continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, the Centers for Medicare & Medicaid Services (CMS) will be transitioning a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). CMS will also be working closely with its claims processing contractors to make sure that Medicare pays correctly in the MSP situations described below.

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.

The following should be noted regarding the planned workload transition:

  • The transition only includes those cases where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly.
  • Beneficiaries and their attorneys will continue to work with the BCRC where CMS is pursuing recovery from the beneficiary.
  • Webinars and town halls will be scheduled in the coming months to provide additional information.

For readers who are not familiar with Medicare’s Commercial Recovery Center, the CRC currently handles Group Health Plans (GHP) recoveries. Therefore, based on this announcement, it is anticipated that all NGHP recovery related activities, where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly, including refund checks, correspondence, and telephone inquiries will be handled by the CRC. This may include recovery demand letters, repayment of debt, administrative appeals request, and notice of intent to refer debt to the Department of Treasury letters.

We do not yet know whether there will be any changes to the current NGHP recovery process as a result of the CRC assuming responsibility for recovery of such conditional payments. As always, Helios Settlement Solutions will continue to track such changes and will continue to inform as to any procedural and administrative effects resulting from same.

The announcement also indicates 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 Ongoing Responsibility for Medicals (ORM).”

The announcement explains that “in situations where an insurer or workers’ compensation entity has reported to CMS that it has ongoing responsibility for medicals (ORM) for specific care, CMS’ claims processing contractors will use the information provided by the insurer or workers’ compensation entity to determine whether Medicare is able to make payment for those claims.” As a result, “insurers and workers’ compensation entities that notify Medicare that they have ORM are strongly encouraged to report accurate ICD-9 or ICD-10 codes as Medicare’s claims processing contractors will use this information to pay accordingly.”

Although we have all known for quite some time that information provided to CMS via the Mandatory Insurer Reporting (MIR) process would be used to determine whether Medicare is the primary or secondary payer of any bill received by Medicare on any given claim, this announcement makes it clear that as of January 1, 2016, CMS will in fact start using the ICD-9 or ICD-10 reported by employer/carrier/TPA/agent to determine whether Medicare should pay or deny such bills.

As a result, with ICD-10 requirements starting October 1, 2015, now more than ever, every employer, carrier, third party administrator, or agent reporting such information to CMS needs to make sure that the ICD-9 or ICD-10 codes provided to CMS are accurate and comply with the applicable guidelines. Not doing so may result in Medicare paying for items it should not have paid for, or denying payments on items it should have paid. Either way, these errors and mistakes may become the source of potential private causes of action under the MSP, or liability and professional malpractice claims away from the MSP.

As an industry leader delivering what I believe to be the best platform for MIR compliance through MedicareConnect℠, Helios can assist RREs, TPAs and insurers ensure the proper use of ICD coding throughout all areas of MSP compliance. Coding the claim correctly means the best possible outcome once the claim is reported to CMS. As a result, Helios recommends the reporting process itself should be reliable and allow for sufficient guidance to ensure the claim is accepted by CMS without the issues of mixed coding or utilization of codes not acceptable by CMS for NGHP Section 111, including where plan type may prevent usage of specific codes. To learn more about Helios’ MedicareConnect℠, please contact us at 888.672.7674, or contactus@helioscomp.com, or www.helioscomp.com/settlement-solutions/medicareconnect-mir.