Here We Go Again, as New Medicare Contractor Takes Over Reimbursement of Conditional Payments When ORM Accepted

Posted by Rafael Gonzalez on Feb 1, 2018 10:06:51 AM

Rafael Gonzalez, Esq., President, Flagship Services Group


After 35 years of seeking reimbursement of conditional payments post settlement, judgment, award, or payment of a case, in 2015, the Centers for Medicare & Medicaid Services (CMS) transitioned a portion of the Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). As a result, on October 5, 2015, the CRC assumed responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity, referred to as Applicable Plans (AP), as the identified debtor. Since then, CMS, through a contract with CGI, had been pursuing recovery directly from APs as the identified debtor when an applicable plan reports that it has ongoing responsibility for medicals (ORM) or otherwise notifies CMS of its primary payment responsibility.

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Topics: MSA, Medicare Law, Conditional Payments

Conditional Payment Compliance Risks for Auto, Liability, No-Fault, and Work Comp Primary Payers

Posted by Rafael Gonzalez on Nov 27, 2017 9:00:00 AM

With Medicare still in financial short and long term trouble, the US Department of Health and Human Services (HHS), and its Center for Medicare and Medicaid Services (CMS), have become increasingly more aggressive about making sure Medicare is the secondary payer pre and post settlement in auto, liability, no-fault, and workers compensation claims. As a result, insurers, self insureds, and third party administrators responsible for payment of auto, liability, no-fault, and work comp claims must be aware of and understand their responsibilities under the Medicare Secondary Payer Act (MSP), and be prepared for the multiple risks associated with MSP compliance. What follows is part two of a four-part analysis of risks associated with each of the MSP compliance components: Mandatory Insurer Reporting (MIR), Conditional Payment Resolution (CPR), and Medicare Set Asides (MSA). This second part focuses on CPR compliance risks for auto, liability, no-fault, and work comp primary payers.


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Topics: Compliance, Liability, Conditional Payments

CMS Publishes Alert for Medical Providers Regarding Accepting Payment from Medicare Beneficiaries with a Medicare Set Aside

Posted by Rafael Gonzalez on Sep 26, 2017 4:00:00 PM

Slowly, but surely, the Centers for Medicare and Medicaid Services (CMS) is making sure medical providers are aware, informed, and prepared to deal with Medicare beneficiaries who must pay their future medical expenses related to a settlement, judgment, award, or other payment from a Medicare Set Aside (MSA). As I blogged about on March 10, 2017, in early 2017, CMS announced a set of codes for Medicare contractors to deny providers’ request for payment of a claim if there existed an open MSA.

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Topics: Liability, Medicare Law, Conditional Payments

Flagship Services Group: The Conditional Payments Resolution Experts

Posted by Rafael Gonzalez on Sep 20, 2017 8:30:00 AM

As we have continued to inform on this blog, at multiple conference presentations throughout the country, and at training sessions for current and potential clients over the last several years, conditional payments resolution isn't just about traditional Medicare any more. Today, conditional payments resolution is about identifying, investigating, analyzing, disputing, appealing, resolving, and closing such claims not just with Medicare Parts A (hospital) and B (physician) coverage, but also with Medicare Parts C (Medicare Advantage Plans) and D (Prescription Drug Plans), as well as Medicaid.

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Topics: Conditional Payments

Resolution of Conditional Payments Continue to Create Havoc on No-Fault Claims

Posted by Rafael Gonzalez on Aug 20, 2017 8:00:00 AM

Medicare conditional payments are serious business. They continue to challenge claims professionals throughout the country. And if not dealt with timely and appropriately, can create havoc on parties’ attempt to settle a claim, or future reimbursement responsibility.

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Topics: Conditional Payments, medicare

Leaving Reimbursement of Medicare Conditional Payments to Plaintiff May End Up Costing You

Posted by Rafael Gonzalez on Aug 16, 2017 1:00:00 PM

We all mean well. Everyone handling claims tries to do the right thing. But sometimes, things just don’t go as planned and end up taking significantly longer than expected and costing way more than agreed.

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Topics: Conditional Payments

CPLs and CPNs are Not Bills

Posted by Gina Cox on May 19, 2017 9:00:00 AM


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Topics: Conditional Payments

Florida Federal Court Orders Beneficiary to Reimburse Higher Conditional Payments, Despite Medicare’s Verbal Representation of Lower Amount Due

Posted by Rafael Gonzalez on Apr 6, 2017 8:00:00 AM

On March 23, 2017, the United States District Court for the Southern District of Florida published its opinion on Shapiro v. Secretary of Department of Health and Human Services, concluding that, even though Plaintiff and her attorney may have relied on Medicare’s verbal representation of $17,306.03 in conditional payments to settle the case, absent a waiver from CMS or its contractors in writing, the MSP Act requires Plaintiff to reimburse Medicare, and permits the Secretary of HHS to recover, the full $23,552.96 it paid in conditional payments from date of accident thru date of settlement. Since Plaintiff did not request a waiver for reimbursing all or part of the debt based on financial hardship, and failed to prove recovery is against equity and good conscience, court concludes plaintiff did not suffer a material detriment as she would still received 96% of settlement proceeds she agreed to.

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Topics: Compliance, Medicare Law, Conditional Payments