By Lou Porrazzo, Esq.
The Commercial Repayment Center (CRC) recently updated internal guidance regarding the treatment of Conditional Payment Letters (CPL) and clarified the process for filing disputes. The CRC has clarified that it will continue to review properly filed disputes on CPLs, and will work with parties to identify CPL Disputes that may have been previously closed out for which additional review is still needed.
Questions regarding CPL disputes arose last month during industry communications with the CRC. During a discussion regarding how CPL Disputes are being processed/adjudicated, the CRC indicated/implied that it would only review CPL Disputes where the debtor or authorized party accepted responsibility for the debt in full or in part. This guidance created concern in the industry.
It is important to understand why CPLs are issued and how they are designed within the framework of the CRC. The Centers for Medicare and Medicaid Services (CMS) and the CRC have described the process to create a CPL as follows:
A CPL will be issued by the CRC when a beneficiary (or their representative) reports a pending case where an applicable plan may have primary payment responsibility for certain care injury and the MSP occurrence was not otherwise reported by the applicable plan itself (through MMSEA Section 111 reporting or by other means). The applicable plan may dispute conditional payments, although there is no specific response due date. The CPL is not automatically followed by the demand letter. The CPL is intended to provide information about conditional payments and allow the applicable plan an opportunity to ensure CMS’ records are correct.
A CPL offers an avenue to dispute the alleged conditional payment amount prior to the demand and directs the debtor to contact the applicable contractor to resolve any discrepancies. A dispute that is filed in response to a CPL is an informal opportunity to address issues identified in the CPL before the potential next step of officially recording the identified debt as a CMS Demand. Under the process outlined in August, during the CRC industry led discussions, there was confusion regarding how debtors and/or the authorized representatives should respond to the CPL. To the CRC’s credit, they met with many professionals in the industry and listened to our concerns. To that end, the CRC has clarified the process for reviewing and adjudicating CPL Disputes. The clarified process is as follows:
- If after reviewing a dispute the CRC agrees to remove all charges, the CRC will issue a Valid Dispute, No Interest letter, or in some cases a Case Resolved letter depending on content of the dispute.
- If the CRC partially agrees with the dispute, meaning that some charges will be removed and some charges will remain, the CRC will issue a demand for payment of the remaining charges.
- If the CRC finds the dispute to be invalid it will then issue a demand for the full amount.
For example, if an insurer receives a CPL from the CRC for $10,000.00, it can file a dispute. If the CRC reviews the dispute and believes that $1,500.00 pertains to related treatment, then the CRC will issue a demand for the $1,500.00. At that point the insurer retains all rights of appeal and can begin the formal appeals process.
Workers compensation and no fault entities retain the ability to continue to dispute CPLs. However, if the dispute does not completely eliminate the conditional payment amount the CRC will then convert the matter to a demand. Parties will still be able to appeal any demand that they deem to be incorrect and retain all associated appeal rights.
This process clarification and guidance from the CRC satisfies the industry’s mandate to continue to dispute unrelated charges while at the same time cutting down on the administrative burden on the CRC. This revised process assures courts that conditional payments are being addressed and we thank the CRC for working with the industry to do so. ExamWorks Clinical Solutions will continue to monitor the situation and will provide updated guidance if and as required. If you need help with any aspect of Medicare conditional payments please contact our Director of Conditional Payment Services, Lou Porrazzo, Esq.
Lou oversees overall conditional payment and Treasury investigations, disputes, and appeals program. An attorney licensed to practice law in Massachusetts, Lou can be reached at firstname.lastname@example.org or 678-256-5085.