CMS Announces Upcoming Transition of Portion of the Non-Group Health Plan Recovery Workload to the Commercial Repayment Center

Sunday, July 5, 2015

On July 2, 2015, the Centers for Medicare and Medicaid Services published a bulletin outlining a change in procedure regarding Medicare Secondary Payer situations and limiting Medicare payments where Ongoing Responsibility for Medicals (ORM) exists.

Effective October 2015: Transition to Commercial Repayment Center (CRC)
Effective October 2015, the Commercial Repayment Center (CRC) will be responsible for handling claims where Medicare is directly pursuing insurers (liability, no fault, self insureds or workers' compensation plans) as the identified debtor for conditional payment recovery. Previously, all claims had been handled through the Benefits Coordination and Recovery Center (BCRC). CMS advised that, in the coming days, webinars and town hall meetings will be convened to provide additional information. Actions directly against a beneficiary for conditional payment recovery will continue to be handled by the BCRC.

The procedural change in the contractor follows the implementation of the Strengthening Medicare and Repaying Taxpayers (SMART) Act appeal provision which allows primary plans to appeal a Medicare conditional payment regarding either its existence or the amount in controversy. Whether separating the contractors will require different policies, procedures, time frames or alter any burden of proof is unclear at this time.

Effective January 1, 2016: ORM Limits
With respect to ORM, effective January 1, 2016 where insurers report, pursuant to the Medicare, Medicaid and SCHIP Extension (MMSEA) Act, that ORM exists, Medicare will use the information to determine whether it will make payment for those claims. In that regard, CMS "strongly" encourages reporting entities to report International Classification of Disease (ICD) 9 or ICD 10 codes accurately. Accordingly, CMS will use the reported codes to discontinue providing medical care to beneficiaries that match the coding, thus limiting its exposure and, presumably, reducing the overall conditional payment recovery potential.

As of October, insurers that have been categorized as identified debtors for conditional payment recovery by Medicare must handle claims through the CRC as opposed to the BCRC. Effective January 1, 2016, acceptance of ORM will limit Medicare payments on behalf of beneficiaries based upon the accuracy of ICD-9 or ICD-10 coding. ExamWorks Clinical Solutions will continue to monitor and analyze all CMS policies and procedures regarding the changes as set out in the Bulletin and will advise its customers on how to implement and operate within the new CRC conditional payment recovery and MMSEA ORM reporting structures.

ExamWorks Clinical Solutions will continue to keep you apprised of all relevant Medicare Secondary Payer compliance developments.

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