No fooling, the Centers for Medicare & Medicaid Services (CMS), Benefits Coordination and Recovery Contractor (BCRC), and Commercial Repayment Center (CRC) got together for an unprecedented joint Town Hall on all aspects of Medicare Secondary Payer reporting and recovery. The call was hosted by CMS’ John Albert but featured Jackie Cipa from CMS, Angel Pagan from the BCRC, Nicole Griffin from the CRC, a number of other key personnel from the agency and its contractors. While the group covered a number of familiar topics, there was even an announcement about a new procedure for reporting certain types of open medical claims.
What’s New?
Angel Pagan outlined some upcoming changes to the Section 111 User Guide. The changes, which are expected in the June update to Section 111 reporting logic, will now allow for alternate reporting in three scenarios where a claim partially resolves but ongoing responsibility for medicals (ORM) remains. The scenarios are:
Partial Resolution with Post-Settlement ORM – Initial Report
In the first scenario, an injured party has a claim with multiple injuries but the same insurance type, policy number, and claim number. On one injury, the parties settle and close out all access to medical care. On the other injury, the claims payer will continue to make ongoing medical payments (as applicable). Basically, this scenario is a partial settlement but it’s a first time report. When that happens, CMS new guidance will be to report two add records. One add record would include the injury that resulted in a settlement, including the total settlement (or TPOC) amount, the TPOC date, and an ORM termination date (if applicable). The other add record would have near identical information, but would include different medical information as well as an ORM indicator of “Y.”
This is probably the least common situation, since it involves an initial report of a partial settlement with post settlement medical. Typically an ORM claim is not initially reported with a settlement.
Partial resolution with Post-Settlement ORM – Subsequent Report
The second situation involves the same circumstance as above, except the claim had previously been reported as ORM for all claimed injuries. When only one of the injuries is settled, CMS would like an “add / update” to be reported. For the settlement, the RRE would file an “add” record indicating the total settlement amount, date, and injury(ies) settled. The RRE would also file a corresponding “update” record for the remaining components of the claim that include only the injuries for which the RRE retains ORM.
While this scenario is more common in some states (e.g. Massachusetts and New Jersey), an “add/update” report represents a new concept. ECS will review the “add/update” scenario and incorporate the logic into our MIR Service and iService platforms as applicable.
ORM Ends for One Injury, Continues for Another, No Settlement
The last scenario involves situations where responsibility for a claimant’s injuries adjusts over time, with some injuries persisting but others resolving and/or becoming denied by the primary payer. When ORM ends for one injury and continues for another with no settlement, the RRE should simply remove the code associated to the terminated injury and file an update record.
This will be a very welcome update for claims payers. While some RREs are likely already performing these updates, in the past we have been cautioned by CMS that such an update wipes the slate clean for that injury for the life of the entire claim. CMS seems poised to incorporate a temporal adjustment to ORM to allow for claims to turn ORM “on and off” for some aspects of an otherwise open claim.
Questions and Answers and Closing Thoughts
Following this announcement, the CRC discussed important reminders about conditional payment timeframes. Specifically, claims payers were reminded that they must file an appeal within 120 days of the receipt of a demand. Absent an appeal during this period, a debtor (either a beneficiary or a claims payer), must demonstrate “good cause” for a delay in the filing or else the appeal will be summarily dismissed.
Participants then took the opportunity to ask a multitude of primarily recovery-related questions in a lively Q&A period. Among other items, questions involved scenarios where a beneficiary refuses to comply with requests for identifying information, whether Medicare’s conditional payment portal allows users to view documents previously submitted, and how to address situations when the debtor disagrees with the contractor’s evaluation of the conditional payment appeal, among others.
This marked the first tri-party Town Hall forum with Medicare, the BCRC, and the CRC. We always learn something new on calls like this and this one was certainly no exception. Here’s hoping that this is the first of many such conversations. If you have any questions about the Town Hall and what was discussed, I’d love to hear from you. Please reach out to me at or 781-517-8085 or martin.cassavoy@examworkscompliance.com
