Interpreting the “Final Rule” on the Conditional Payment Appeals Process

Posted by Kendell Gracey on Jul 23, 2015 6:00:00 AM

YOU_ARE_SIMPLY_THEOn December 27, 2013, Centers for Medicare and Medicaid Services (CMS) issued a Proposed Rule regarding how “applicable plans” like P&C insurance, workers’ compensation, and no-fault insurance, could appeal conditional payments demanded by Medicare.

As of April 28, 2015, the “final rule” on this matter went into effect.

While there was much debate and exploration of ideas batted back and forth over the TBD-month interim, the final rule is actually essentially the same as the proposed rule with no substantive changes.  A number of public comments and requests were reviewed by CMS but all requests ended up being declined for various reasons as explained in Section Two of the final rule statement.

Some quick highlights of the rule:

  • The appeal rights for applicable plans is essentially the same as those available to individual beneficiaries.
  • It is a four-level appeals process that includes working through the CMS contractor, a Qualified Independent Contractor, an Administrative Law Judge, and the Medicare Appeals Council of the Department Appeals Board.
  • The process is limited to appealing the amount of the conditional payment demanded by Medicare in a Final Demand Letter and does not include the option to appeal who Medicare is demanding the payment from.
  • While Medicare declined to provide notice to all parties involved when a Final Demand Letter is issued, they will be notifying the beneficiary if an applicable plan files an appeal involving that beneficiary’s claim.
  • This final rule has no bearing on appeals involving Medicare Set-aside Allocations (MSAs) for future medical costs.

Pros and cons of the final rule still remain to be seen. What we know at this point is how the process is supposed to work, and what applicable plans can expect.  Like all our clients and colleagues, we’ll be paying close attention to how everything pans out in practice and we’ll be sure to keep our clients abreast of the very latest.

If you want to ensure that your “applicable plan” is 100% Medicare compliant, whether an appeal is required or not, let’s talk about how we can make that happen.

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Topics: Claims Processing