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

By: Rafael Gonzalez, Esq., President, Flagship Services Group

After 35 years of seeking reimbursement of conditional payments after 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, has 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.

Stakeholders Unhappy with CRC Lack of Responsiveness

As the CRC assumed responsibility for the recovery of conditional payments where CMS was pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity as the identified debtor, NGHPs began to notice a considerable slow down of requests for reimbursement. In response to such industry wide concerns, on February 9, 2016, the CRC announced it “was aware that many insurers and work comp entities were concerned and awaiting demand letters.” 

Over the next several months, workers compensation and no-fault claims professionals discovered what they had been fearing all along, that CGI, the federal contractor hired by CMS to do the CRC day to day work required to administer such ORM claims, had no experience in NGHP work, let alone an understanding of workers compensation and no-fault claims, process, structure, policies, coverage, benefits, settlement, exhaustion, limits, timing, state laws and requirements affecting reimbursement of conditional payments. As the months went by, it also became evident that there was no internal system or process at CGI to handle all of the various components of conditional payment resolution in situations where an AP had accepted ORM. Individuals at CGI answering questions from NGHP entities would often indicate they had not been trained in the specific workers compensation or no-fault issue at hand. This resulted in NGHP entities receiving inaccurate and inconsistent answers and information, thereby extending, by several months, the resolution of such issues.

Stakeholders Share Concerns During CMS Meeting on CRC Progress 

The CRC process was front and center at the November 17, 2016 CMS townhall telephone conference. After CMS updated listeners on the Medicare Secondary Payer Recovery Portal (MSPRP) and Social Security Number Removal Initiative (SSNRI), the CRC had the opportunity to present on lessons learned since taking over resolution of ORM claims on October 5, 2015. Although it was clear that the process had improved regarding group looping, and accuracy of the conditional payments, the backlog remained an issue. Although the CRC shared timeframes within which each step of the process, the reality was that cases were taking longer and longer at the CRC. 

CMS Announces Change to CRC Contractor

Although no mention of why, on October 10, 2017, CMS announced it had taken CGI off and instead awarded the new CRC contract to Performant Recovery, Inc. for recovery activities for both Group Health and Non-Group Health Plans (that is, liability insurance (including self-insurance), no-fault insurance, and workers’ compensation laws or plans) with ongoing responsibility for medicals. At that time, CMS indicated “activities would be transitioned in a manner that preserved continuity and presented minimal disruption to the recovery process. CMS anticipated completion of the transition process by early January, 2018.” 

On January 5, 2018, CMS announced it would be presenting two webinars to introduce the new CRC Contractor. The GHP webinar will be held Wednesday, January 17th and the NGHP webinar on Thursday, January 18th. The same notice indicated that effective February 8, 2018, the new contractor would assume responsibility of the CRC functions, including 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 as the identified debtor. 

Conclusion

Here we go again, as a new CRC contractor takes over reimbursement of conditional payments when ORM exists. After more than two years since the CMS transitioned a portion of the NGHP recovery workload from the BCRC to the CRC, CMS announced a change of contractor handling the day to day administrative components of such reimbursements from CGI to Performant Recovery. Because of volume, the ongoing nature of ORM, and the potential for mistakes, most expected for the CRC to experience difficulty early on with 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, as the identified debtor. However, more than two years into it, most also expected for the CRC process to be better developed, for customer service representatives to be better informed, for communication channels to have been more clear and transparent, for the transfer of data and documents to be easier and smoother, for the conditional payment summaries to be more accurate, for the dispute process to be more consistent and faster, and for resolution to bring closure. With a new contractor that does not have a background in liability, no-fault, or workers compensation claims, or any experience handling MSP issues, all stakeholders will be watching closely as Performant takes over February 8, 2018. 

LIVE education Tuesday, January 23, 2018 "2018 Medicare Secondary Payer Issues & Compliance Update" In St. Pete Beach, FL

About Rafael Gonzalez

Rafael Gonzalez, Esq. is President of Flagship Services Group, a 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. He has been a part of the insurance, medical, and disability industries since 1983. He has served as a thought leader on all aspects of liability, workers compensation, social security, Medicare, and Medicaid compliance since 1990. He speaks and writes on mandatory insurer reporting, conditional payment resolution, set aside allocations, advantage plans, Medicaid third party liens, special needs trusts, as well as the interplay and effect of these processes and systems and the Affordable Care Act throughout the country. Rafael is very active on LinkedIn, Twitter, Facebook, and 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