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This year, CMS has been quite active announcing several updates to its Medicare Secondary Payer Recovery Portal and holding a recent webinar on redetermination requests. CMS trends regarding post-settlement Total Payment Obligation to Claimant (TPOC) beneficiary recovery have been causing some challenges for workers’ compensation carriers from another angle. CMS will also be holding a webinar on the NGHP Beneficiary Recovery Process on December 9th.

In September, CMS and the Commercial Repayment Center (CRC) held a webinar session to address “redetermination” requests as part of the administrative appeals process regarding conditional payment disputes of non-group health plans (NGHP). CMS reviewed the five levels of the administrative appeals process before the CRC discussed the various appeals available to primary payers in the administrative appeals process.

The CRC outlined the specific arguments it will accept as part of a redetermination request as follows:

— Termination of Ongoing Responsibility for Medicals (ORM) due to benefits exhaustion;
— Termination of ORM due to settlement or other claim resolution;
— Benefits denied/revoked by applicable plan;
— Non-covered services;
— Unrelated services; and
— Duplicative primary payment.

As part of this session, the CRC emphasized adherence to established appeal timelines and other related requirements is critical. On this point, the CRC advised redeterminations must be received within 120 days from the date a Medicare demand letter is received by the named debtor, which CRC noted is presumed to be five days after the date of demand.

CMS’s trend of having the BCRC pursue the claimant post-settlement is currently causing some challenges and frustration particularly in workers’ compensation settlements.

Specifically, the BCRC is increasingly opening conditional payment recovery cases upon receipt of TPOC information and issuing final demands with the claimant named the debtor. This occurs even in situations where the parties have previously worked with the CRC to resolve conditional payment cases related to ORM.

When this happens, the carrier cannot interact with the BCRC on the claim without having a separate Proof of Representation (POR) executed by the claimant. This, in turn, complicates the workers’ compensation carrier’s ability to ensure that Medicare’s recovery is resolved if they cannot secure a POR from the claimant post-settlement.

To prevent this, workers’ compensation carriers wishing to ensure conditional payment exposure is fully resolved may need to consider securing a POR from the claimant as part of the settlement process to avoid having to chase the claimant post-settlement for this required authorization.

CMS has recently announced that it is holding a Non-Group Health Plan (NGHP) Beneficiary Recovery Process Webinar on December 9, 2020, at 1:00 p.m. ET. CMS indicates that its primary intended audience is “attorneys who represent beneficiaries and other beneficiary representatives.”