The Commercial Repayment Center (CRC) has been on the job for the last eighteen months. It’s time for a progress report on this contractor, which has reset the timeline for conditional payment investigations.
More recovery collection notices are being issued.
We have seen a slow evolution with the CRC. The CRC began non-group health plan (NGHP) recoveries in October 2015. The CRC’s mandate is simple: recover on Medicare’s behalf whenever a Medicare conditional payment has been made, regardless of settlement, and whenever an insurer has ongoing responsibility for medical bills. For the first four months, the CRC provided few conditional payment notices. Slowly but surely, the CRC provided more information throughout 2016. By the end of the year, the CRC issued more and more recovery collection notices.
Contractors are challenged.
There have been some growing pains as the CRC has gotten its feet wet in the conditional payment space. The CRC sought recovery on claims that appeared unrelated to the workers’ compensation or no-fault claim; issued letters simultaneously with the Benefits and Coordination and Recovery Contractor (BCRC) on the same claims; stopped issuing letters for long periods; and wrestled with disputes and appeals that were new and challenging. These issues materialized at various times from October 2015 to the present. Usually they have been resolved or mitigated quickly, but they still represent major issues for the contractor.
Several challenges remain. It can be frustrating to receive many conditional payment notices or demands that are not anticipated, yet not receive the demand or notice that you have been seeking for several months. The portal has improved in the last six months, but there is often a disparity between what the portal says and what any letter received from the CRC says. We should be able to rely on the portal as a source of information, but the CRC is not there yet.
Use these must practices in handling these cases.
If you have an open workers’ compensation or no-fault claim involving a Medicare beneficiary, by now you have seen a conditional payment notice. Fret not, here are five things to think about when dealing with a Medicare beneficiary whose claim could be subject to a CRC recovery action:
- Focus on what you can control – You have access to the same Section 111 Mandatory Insurer Reporting data that Medicare and the CRC have. You know what claims involve Medicare beneficiaries and what claims do not. You know what claims have been reported to CMS and what injury codes have been reported. Get on top of this information. Make sure it was timely and reported accurately. If something changes in a claim, make sure Medicare is notified in a timely fashion and in an accurate record update.
- Act swiftly and proactively. – As soon as you learn that your workers’ compensation or no-fault claim involves a Medicare beneficiary, act quickly to investigate conditional payments. Do not be caught flat-footed months or years after a claim has closed administratively but remains open technically in the eyes of Medicare and the CRC.
- Be aggressive. –Insurers and TPAs should engage and act aggressively when faced with a conditional payment notice or a conditional payment demand. Time is short and the CRC’s demands often overstate the appropriate conditional payment amount. The CRC provides 30 days to dispute a conditional payment notice (CPN), so act quickly if you think you can, in good faith, dispute the CPN. Once a demand is issued, the SMART Act’s new primary payer appeals process provides insurers and self-insureds 120 days to file an appeal. Use this time to marshal the information you need and contest claims for relatedness, state law issues, the denied nature of the claim, and more.
- Ignore the noise and focus on resolving the case. – The CRC will tell you that there is still considerable on-the-job learning in effect. If a representative at the CRC explains something that doesn’t sound quite right, then they could be mistaken. Do not be afraid to work within the system, to double and triple check, to make sure that the conditional payment dispute process is being followed, or that CRC has interpreted the injury, the authorizations, or anything else in the case properly.
- Rinse and repeat. – It’s critical to remember that the CRC is within its rights to recover multiple times on the same file. As long as the Ongoing Responsibility for Medicals (ORM) status remains set to “Y,” Medicare’s contractor will recover if it believes conditional payments could have been made on the claim. Keep this in mind when handling Michigan PIP or Texas workers’ compensation or states similar to Texas where ORM may never terminate, at least until CMS updates its ORM termination policy.
ExamWorks Clinical Solutions’ (ECS) team has been working diligently on these conditional payment issues since the CRC’s arrival on the scene nearly 18 months ago. We are focused on the prompt identification, mitigation, and resolution of these cases, always with our clients’ best interest. We will follow developments with the CRC and work to identify any issues proactively that could impact settlement or resolution, as they arise. For questions about ECS’ conditional payment services, please contact your ECS representative or call 678-222-5300.
About the author
Christie Britt is the Senior Vice President of Operations of ExamWorks Clinical Solutions. She has vast knowledge of Medicare set asides and MSP Compliance. Prior to ECS, Christie worked for a decade in claims management, followed by twelve years in all aspects of MSP compliance. She has developed and enhanced products and operational efficiency models that support growth while ensuring quality. Christie also served as the Director of Financial Operations for Rising Financial Solutions and the Director of Operations for Health Advocates, Inc. PMSI MSA (formerly Helios and now Optum). Christie is MSCC and CMSP certified and has a Green Belt certification in Six Sigma. She is a member of the National Association of Medicare Set Aside Professionals and the Workers’ Compensation Claims Professionals. Christie received a B.S. in Marketing and Economics from the University of South Florida. She earned an M.B.A. from the University of South Florida with disciplines in Healthcare Administration, Quality Management, and Economics.