Wondering why you are getting so many conditional payment demands from Medicare?

The Centers for Medicare and Medicaid Services (CMS) wants their money back and is going after payers to get conditional payments reimbursed. CMS has been sending notices to payers demanding payment, but many of the notices are going unanswered. That creates a two-fold problem. Interest accrues on the balance, and if there’s no response, the U.S. Treasury could seize the assets of the payer (i.e., carrier or self-insured employer).

Key points to understand

• Medicare might make a conditional payment when there is evidence that the primary plan will not pay promptly ― conditioned upon reimbursement by the primary plan or beneficiary.
• Claim data reported to CMS through the MMSEA MIR Section 111 reporting process is shared with Medicare’s recovery contractors ― the Commercial Repayment Center (CRC) and Benefits Coordination & Recovery Center (BCRC) to aid in recovery.

Things to watch when reporting claims through Section 111

• Only send the accepted ICD codes associated with the claim
• Terminate Ongoing Responsibility of Medical when the claim settles or applicable by state law
• Submit Total Payment Obligation to Claimant when appropriate

A claim should be referred to Optum for Conditional Payment services if:

• The CRC has the responsibility to recover conditional payments when CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity (LNFWC) as the identified debtor which has accepted ongoing responsibility for medical care.
• There are unrelated charges on the notice for reimbursement
• There is a discrepancy with the MMSEA Section 111 reported data and what is on
  the notice
• Multiple dates of loss and/or multiple letters/notices/demands are received for the same claimant
• Multiple parties are involved with the claim due to apportionment/exposure matters
• The Conditional Payment is incurring interest
• The Conditional Payment has been referred to the Department of Treasury or Treasury Offset Program

If you have any questions, please contact 1-888-MSA-7674 or email OptumMSA@optum.com

For information on the basics of conditional payments, please click here.