Tag Archives: COBC

MSP Predictions for 2014

  1. 1. Conditional Payment Processes will improve- CMS announced on December 23, 2013 that it will launch the Benefits Coordination and Recovery Center (BCRC) on February 1, 2014. The two units that will be consolidated are the Coordination of Benefits and the Medicare Secondary Payer Recovery units. They will collectively be called the BCRC, and the consolidation is aimed at creating greater efficiencies in resolving claims and eliminating confusion caused by two separate contractors. The new BCRC should accelerate conditional payment disputes and make the overall process easier. However, it has been rumored that the new BCRC will pursue conditional payment reimbursement on cases where open ORM is reported. Traditionally, Medicare only seeks reimbursement of conditional payments after a case settles or TPOC is reported. This will create additional revenue for Medicare in that it will be able to recover conditional payments on cases where future medicals remain open.
  2. CMS/WCRC WCMSA Processes will also improve- the WCRC should continue to improve their communication with the industry on their allocation methodology. In 2013, the WCRC issued a more detailed WCMSA Reference Guide, held their first WCMSA teleconference, and turnaround times on WCMSA approvals vastly improved. In 2014, it is expected that the WCRC will continue with their efforts to make the WCMSA process quicker, smoother and more predictable for all involved.
  3. Continued Divergence of Case Law on LMSAs will continue- In 2013, we saw a great deal of case law where parties to liability settlements brought their LMSA disputes to the court system hoping for resolution on the potential need for an LMSA. We had jurisdictions that refused to intervene on the LMSA issue- in Florida in the Early v. Carnival Corp. case, the court found that intervening on whether an LMSA was required would amount to issuing an “advisory opinion” and therefore the court declined opining on the need for an LMSA. However, in Mississippi in the Welch v. American Home Insurance Company case, the court not only reviewed the proposed amount of the LMSA, but increased the amount that was needed! These are just a few examples that demonstrate case law with regard to LMSAs was all over the map last year.This could potentially be resolved in 2014 if CMS continues working on the rulemaking concerning MSP and Future Medicals. As we blogged about in August of last year, CMS noted on its regulatory calendar that it was going to resume its rulemaking on this topic this past September.  However, CMS did not take any further action on this topic in 2013.  If CMS resumes the process on this in 2014, we could receive clarity as to obligations with regard to future medicals in liability settlements with Medicare beneficiaries.
  4. The SMART Act: Rulemakings will set the stage for action in 2014, however most items will not be in place until 2015 or later. In 2013, CMS issued several rulemakings pertaining to required action items from the SMART Act.
  • First, CMS issued an interim final rule which would create a conditional payment web portal. While CMS is applauded for taking action on this item from the SMART Act, the interim final rule left much to be desired, with one of the main disappointments being that the roll-out deadline would be January 1, 2016. One can only hope that the comments received on this interim final rule will push CMS to roll out the portal sooner than indicated as well as resolve other issues present in the interim final rule. However, because CMS has indicated that roll-out will be January 1, 2016, it is unlikely that we will see much action on this item this year.
  • Second, CMS issued an ANPRM which would carve out circumstances where penalties could be imposed for violations of MMSEA Section 111 reporting requirements. We may see some movement and actual rules carved out in 2014 for the circumstances where CMS may issue penalties. However, until the process is set into place, which will likely not be until mid-end of 2014, we will not see penalties
    issued. Our prediction on this item is that actual penalties will not be issued until sometime in 2015.
  • Third, CMS issued an NPRM for an appeals process to be utilized by applicable plans for conditional payment disputes. It appears likely that this appeals process could be rolled out this year, in that it is only for conditional payments (and not WCMSAs), and because it will mirror the existing appeals process currently in place for Medicare beneficiaries.
  • Lastly, we will see pressure on CMS this year to create and publish an annual threshold wherein conditional payments would not have to be reimbursed and the settlement would not be reportable under MMSEA Section 111. This action item of the SMART Act should have already been in effect; CMS was supposed to publish this amount on November 15, 2013 and the threshold would have begun on January 1, 2014. But CMS did not take action on this item in 2013. We should see that pressure upon CMS from the industry aas well as MARC (who was responsible for getting the SMART Act approved) will force a hand in publishing this threshold.

2014 should be an interesting year full of MSP-related events. Count on PMSI Settlement Solutions to keep you up to date, in compliance, and ahead of the curve!


CMS Releases Updated NGHP User Guide Version 4.0

CMS has released an updated User Guide for NGHPs. Although the User Guide is dated October 7, 2013, it was not released to the public until October 18, 2013. Access to the updated User Guide can be found here.

User Guide 4.0 incorporates changes announced via alerts over the past several months in relation to the conversion to ICD-10 coding with respect to MMSEA Section 111 Mandatory Insurer Reporting.

PMSI encourages RREs and claim administrators to review the new User Guide in its entirety to ensure compliance.  However, we have noted the following as a summary of the more significant updates included in the new User Guide:

  • Inclusion of three June 2013 alerts regarding transition to ICD-10, testing for
    ICD-10 codes, and new ICD-9/10 excluded codes.
  • Layout changes to the claim input file detail record include repurposing of the ICD-9 fields to accommodate ICD-10 code lengths by adding spaces that were reserved for future use in previous editions of the Guide.  A new ICD indicator has also been added from reserved space and will be used to indicate which coding has been utilized within the claim.
  • Inclusion of updated hyperlinks on Medicare and COBC web pages where outdated hyperlinks existed.
  • Disposition code 50 has been clarified; CMS indicates that RREs should only expect to receive a low volume of responses with this code.
  • Computer Based Training (CBT) Modules: Users no longer need to register for CBTs and the modules can be accessed directly from the CMS website.

In addition to the updated User Guide, CMS issued a revision to the August 14, 2013 alert regarding diagnosis codes that are no longer valid for reporting as of January 6, 2014. This revision adds ICD-10 cluster codes related to diabetes to the list of invalid codes. A copy of the revised alert can be obtained here (CMS has indicated changes with a bold font for ease of reference).

Government Shutdown and Impact to MSP and CMS (Part 2)

On September 30th, we issued a blog about the government shutdown and predictions as to how it would affect the various operations at CMS and other entities charged with MSP operations. Please click here to read our prior blog.

As our subscribers are probably aware, it has now been over a week since the government shutdown commenced and it is unclear as to when it will cease.  PMSI would like to provide the following update to its subscribers:

CMS Approval Letters and the WCRC:

Over the past week, PMSI has still been receiving MSA approval letters from CMS, although fewer than usual. PMSI has learned from its contacts at the WCRC that the CMS Regional Offices are operating with a “skeleton crew,” and therefore some CMS approval letters are still being issued. However, approval letters are not being issued at normal volume and therefore the industry can expect fewer approval letters than usual until the shutdown ceases.

If a call is placed to any of the CMS Regional Offices, your call will be responded to with the following message: “Due to the absence of either a fiscal year 2014 appropriation, or a continuing resolution for the Department of Health and Human Services, our offices are in furlough and we are not able to respond to your message.”

Conditional Payment Processes and the MSPRC:

Over the past week, the MSPRC appears to be operating normally as predicted and the conditional payment process appears to not be affected.

As usual, PMSI will continue to keep our subscribers updated on the government shutdown and any affect it may have on the MSP processes.

Updated WCMSA Regional Office Contact List

CMS has posted an updated contact list for its regional offices that review WCMSAs. The updated contact list can be located here.