At Flagship, When We Say $585 to Handle All Aspects of Conditional Payments in Auto, No-Fault, Liability, and Work Comp, We Mean it!

Posted by Rafael Gonzalez on Jan 23, 2017 6:52:22 PM

When We Say $585 to Handle All Aspects of Conditional Payments in Auto, No-Fault, Liability, and Work Comp, We Mean it!Resolution of Medicare conditional paymentsis getting more and more complex, becoming harder and harder, taking longer and longer, and more and more expensive for auto, no-fault, liability, and workers compensation primary payers. More and more often, we hear stories of such primary payers and their third party administrators paying thousands of dollars to vendors to handle their Medicare conditional payment resolution process.

Although primary payers are told by such vendors that there are “only minimal fees” associated with handling their conditional payments, auto, no-fault, liability, and work comp insurers, re-insurers , and their third party administrators are getting billed percentage of savings, or charged piecemeal based on each activity or item filed with CMS, sometimes totaling thousands of dollars.

At Flagship, resolution of conditional payments is our expertise, our sweet spot, our bread and butter. As CMS has evolved its conditional payment process by bringing in contractors (BCRC and CRC) to handle conditional payments, Flagship has built a team of processors, claim analysts, nurses, and attorneys that dedicate 100% of their  time to resolving auto, no-fault, liability and work comp conditional with the BCRC and CRC.  Because we know who to speak with, what to argue, when to communicate, which document works best, and how to obtain the best results, Flagship charges a flat fee of $585 for all work associated with and needed to completely resolve these Medicare conditional payments.

It doesn’t matter how long the case takes to resolve, how long each task may take, how many times we have to go back to CMS to check for updates, or challenge unrelated payments, we only charge $585! And if the primary payer utilizes Flagship’s mandatory insurer reporting (MIR) services, allowing us to identify and validate ongoing responsibility for medical (ORM), ICD-9 and ICD-10 codes related to the claim, and total payment obligation to claimant (TPOC) in all of their Medicare Secondary Payer (MSP) files, depending on volume, we can and have contracted with property and casualty clients for significantly less per file.

Over the last 5 years, we have handled over 25,000 conditional payment claims of all types and sizes. You name it, we have seen it, worked it, and resolved it for our property and casualty clients. We could share with you hundreds and hundreds of cases where we have saved our clients millions of dollars in conditional payments. But instead, I would like to share with you examples of the type of cases and the type of results we produce for clients every day throughout the country.

Medicare Conditional Payments Resolution Compliance Program

Workers Compensation Claim

The Claimant, a Medicare beneficiary, had an accident in the course and scope of his employment on 08/10/2007. Our client, a national workers compensation carrier, accepted the work comp claim, paying disability benefits and medical care, which included an L5-S1 fusion with spinal cord stimulator. While compensability of injuries to L2, 3 & 4 and psychiatric care were being litigated, on 2/11/2016, the claim was referred to Flagship for investigation and resolution of any conditional payments made by Medicare. On 2/29/2016, Flagship received a Conditional Payment Letter indicating Medicare had made $2,596.76 in payments related to the work comp claim. After reviewing these, Flagship disputed all payments made by Medicare, as none were related to the work accident. On 4/15/2016, Flagship received an updated CPL for $0. After informing client of same, client informed us they were getting ready to settle the case. As a result, on 6/30/2016, Flagship requested an updated CPL from CMS. On 8/4/2016, Flagship received an updated CPL for $694.03. Flagship immediately submitted a dispute to Medicare challenging all claims, as none were related to the work comp claim. On 8/24/2016, Flagship again received an updated CPL agreeing with Flagship’s dispute and again reducing the amount owed to $0.

After informing our client of same, Flagship received settlement information indicating settlement of the claim for $62,000. As a result, on 9/5/2016, Flagship submitted settlement information to CMS and requested a Final Demand. In response, on 9/20/2016, Flagship received a Final Demand for $30,967.73. Immediately, Flagship submitted a Request for Redetermination, arguing that based on the ICD-10s reported by the client through Mandatory Insurer Reporting (MIR) as related to the work comp claim, all but $728.79 were unrelated charges. On 10/13/2016, Flagship received a Favorable Redetermination Letter with new amount of $728.79 due. After informing client of same and recommending payment of same, on 11/21/2016, Flagship received a Case Closure Letter acknowledging receipt of check for $728.79, showing $0 owed, and closing the file.

Flagship therefore saved the client $30,239.44 ($30,967.73 - $728.29 = $30,239.44). Client’s cost for all of this - $585.

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No-Fault Claim

The Claimant, a Medicare beneficiary, was hurt in an automobile accident on 12/8/2014. Our client, a national property and casualty insurer, provided no-fault coverage to the claimant as a result of the rib abrasion and contusion related to the accident. Because the claimant was a Medicare beneficiary and the no-fault carrier had accepted ORM on the file, on 5/13/2015, the claim was referred to Flagship for verification and resolution of any conditional payment made by Medicare. After reporting the claim to the BCRC, and submitting authorization forms to the BCRC, on 6/11/2015, Flagship requested a Conditional Payment Letter. After receiving a Conditional Payment Letter on 7/23/2015 for $14,307.76, Flagship updated our client and asked for claims status. On 10/20/2015, Flagship checked again with CMS on an updated amount. As of 10/17/2015, the Conditional Payment amount was still $14,307.76. On 2/1/2016, Flagship checked again with BCRC, requesting a copy of updated Conditional Payment Letter. On 2/12/2016, we received an updated Conditional Payment Letter dated for $14,383.92.

After updating our client and asking for claims status, on 2/16/2016, we learned the claim remained open and claimant was still treating. After several updates from the claims adjuster, we learned claimant stopped treating and that policy limits of $50,000 had not been exhausted. As a result, on 8/12/2016, Flagship requested an updated Conditional Payment Letter. On 8/29/2016, we received an updated Conditional Payment Letter for $28,197.06. After updating our client and receiving closure information from the claims adjuster, on 9/20/2016, we submitted a dispute to BCRC challenging the entire amount as unrelated charges. On 10/5/2016, we received a response from BCRC in full agreement with our dispute. As a result, on 10/5/2016, we submitted closure documents to BCRC and on 11/15/2016, received Case Closure Letter from BCRC confirming Medicare’s file is closed.

Flagship therefore saved the client $28,197.06. As is typical in all of our claims, we not only checked once or twice for updated conditional payments, but in this case checked five times before the matter was ready to be closed, and then challenged all payments made by Medicare that were unrelated to the claim. And again, all of this at a cost of $585.

Liability Claim

The Claimant, a Medicare beneficiary, had an accident on 7/26/2014, during which he sprained his left ankle and injured his left knee. Our client, a national property and casualty insurer, received a Conditional Payment Letter on 6/9/2016 for $29,689.41. On 6/17/2016, our client referred the claim to Flagship to investigate and challenge the Conditional Payment Letter. After submitting authorization forms to Medicare and challenging over $22,000 in unrelated charges, on 8/23/2016, we received an updated Conditional Payment Letter dated 8/19/2016 for $24,773.37. Disagreeing with BCRC’s decision, on 8/31/2016, we submitted a second dispute to BCRC based on unrelated charges. On 9/28/2016, Flagship received notification that Medicare agreed with our dispute, updating the Conditional Payment amount to $2,299.23. After receiving information on 10/1/2016 that the claim settled for $10,229.23 on 9/30/2016, we submitted closure documents to BCRC. On 10/18/2016, we received Final Demand dated for $2,290.33. After sending our client the Final Demand Letter with instructions to pay, on 11/5/2016, Flagship received Case Closure Letter from BCRC confirming Medicare’s file is closed.

Flagship therefore saved the client $27,399.08 ($29,689.41 - $2,290.33 = $27,399.08). As is typical in all of our claims, we not only checked several times for updated conditional payments, but in this case challenged unrelated payments made by Medicare twice. And again, all of it at a cost of $585. Unlike other vendors that charge a percentage of savings, or charge piecemeal based on each activity or item filed with CMS, or charge a flat fee but only check with Medicare once, or challenge payments only once, Flagship charges a flat fee of $585 for all work associated with and needed to completely resolve Medicare conditional payments in liability cases. Doesn’t matter how long the case takes to resolve, or how long each task may take us, or how many times we have to go back to CMS to check for updates, or challenge unrelated payments, we only charge $585!

$585, We Mean It!

Flagship charges a flat fee of $585 for all work associated with and needed to completely resolve Medicare conditional payments in auto, no-fault, liability and workers compensation cases. Doesn’t matter how long the case takes to resolve, or how long each task may take us, or how many times we have to go back to CMS to check for updates, or challenge unrelated payments, we only charge $585! And if the primary payer utilizes Flagship’s mandatory insurer reporting (MIR) services, allowing us to identify and validate ongoing responsibility for medical (ORM), ICD-9 and ICD-10 codes related to the claim, and total payment obligation to claimant (TPOC) in all of their Medicare Secondary Payer (MSP) files, depending on volume, we can and have contracted with property and casualty clients for significantly less per file. To contact us about our mandatory insurer reporting and conditional payment resolution services, you may reach us at 888.444.4125 or email us at info@flagshipsgi.com or visit us at www.flagshipservicesgroup.com.

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About Rafael Gonzalez

Rafael Gonzalez, Esq. is President and Chief Legal Counsel at Flagship Services Group, the only national Medicare Secondary Payer services provider focusing on and offering comprehensive mandatory reporting, conditional payments, and set aside allocation compliance services to the property and casualty insurance industry, including auto, no-fault, liability and work comp self-insureds, insurers, re-insurers, and third party administrators. Rafael blogs on these topics at Medicare Compliance for P&C Insurers at http://www.flagshipservicesgroup.com/blog. He can be reached at rgonzalez@flagshipsgi.com or 813.967.7598.

Topics: Liability