Franco Signor LLC

This great new piece provides a nice “round-up” of current conditional payments updates and trends – including MSPRP (portal) updates, CRC’s recent activity concerning redetermination requests, and the growing issues and challenges related to post-settlement TPOC beneficiary recovery. CMS will be holding a NGHP Beneficiary Recovery Process Webinar on December 9, 2020 at 1:00 p.m. ET. As part of this upcoming event, CMS notes that it plans to focus on the MSP recovery process when a Medicare beneficiary receives a settlement, judgment, award, or other payment; a “refresher” on the beneficiary recovery process, including what functions can be facilitated using the MSPRP; as well as providing information on its alternative demand calculation options (Self-Calculated Conditional Payment Amount and Fixed Percentage Option) and beneficiary recovery tips and best practices. Parties interested in attending CMS’s webinar should follow the registration information as outlined in CMS’s notice.

As part of this update, authorized and authenticated users logged into the MSPRP using multi-factor authentication (MFA) can now view additional information on the “View/Dispute Claims Listing” page of the MSPRP. Specifically, when viewing the claims listing, an authorized and an authenticated user can sort and filter the listing of charges Medicare is seeking reimbursement for using several columns. This spreadsheet, per CMS, should contain the full listing of charges for which Medicare is seeking reimbursement, including the provider name, dates of service, ICD codes, relevant DRG/CPT/HCPCS codes, charged amount, Medicare reimbursement amount, and conditional payment amounts. In 2019, we saved our clients $59 million in conditional payment disputes and reduced 65% of conditional payment dispute submissions to zero dollars.

The Centers for Medicare and Medicaid Services (CMS) has just released its latest version of the WCMSA Reference Guide (Version 3.2, October 5, 2020). CMS summarizes the updates in Section 1.1, which relate to the major medical centers that the Workers’ Compensation Review Contractor (WCRC) uses to price future medical expenses in WCMSAs. This recent update also moved the “List of Previous Version Changes” to Appendix 8, and designated Appendix 7 as a list of the major medical centers – organized by state, NPI, and zip code. Specifically, when a WCMSA is submitted through the WCMSAP, there’s a new prompt requiring the submitter to confirm whether the WCMSA includes any costs associated with a major medical center and if so, to provide the appropriate zip code.

Reviewing these pages indicates that CMS has made updates to Chapter III (Policy Guidance) regarding the calculation of the total payment obligation to the claimant (TPOC) amount providing updated guidance around “property damage only” claims and “indemnity only” settlements. The computation of the TPOC amount includes, but is not limited to, all Medicare covered and non-covered medical expenses related to the claim(s), indemnity (lost wages, property damages, etc.), attorney fees, set-aside amount (if applicable), payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), and amounts forgiven by the carrier/insurer. Overall, Responsible Reporting Entities (RREs) will likely find these updates helpful concerning their Section 111 reporting obligations and in light of CMS’s outstanding Section 111 civil money penalty (CMP) proposals. In addition to the updates to Chapter V, Appendix J, referenced in the preceding section, CMS has also separately published updated versions of their accepted and excluded ICD-9 and ICD-10 code listings for 2021.