by William A. Green, Esq.

The Center for Medicare and Medicaid Services (CMS) recently announced major changes to the conditional payment recovery process. The most significant change involves a 30-day deadline to dispute charges.

Effective October 5, 2015, once a Conditional Payment Notice is issued, workers’ compensation insurance carriers will have 30 days from the date of the Notice to dispute whether the conditional payments are related to the accepted claim. If the carrier does not challenge the Conditional Payment Notice within 30 days, the CRC (Commercial Repayment Center) will assume such payments are related to the accepted claim and issue a Demand Letter (also called an “initial determination”). The applicable plan will have 60 days from the date of the Demand Letter to issue payment without the accrual of interest. Additionally, the carrier can appeal the amount included in the Demand Letter, by requesting a “redetermination” by the CRC. From there, the applicable plan may further contest the conditional payment amount by following a multi-level appeals process. However, interest on the conditional payment amount will continue to accrue during the appeals process.

If the workers’ compensation insurance carrier does not resolve the conditional payment debt within 120 days of the Demand Letter, the CRC will issue a Notice of Intent to Refer Letter. The applicable plan will have 10 days from the date of the Notice of Intent to Refer Letter to pay the debt with interest. Otherwise, the CRC will refer the debt to the Department of the Treasury, which may enlist the Internal Revenue Service (IRS) or the Department of Justice to collect the debt.

Also, it should be noted that as part of the changes effective October 5, 2015, CMS transitioned a portion of the Non-Group Health Plan (NGHP) recovery process from the Benefits Coordination & Recovery Center (BCRC) to the CRC, mentioned above. The CRC will assume responsibility for conditional payment recovery in all new cases where CMS is pursuing recovery directly from a workers’ compensation entity (insurer or servicing agent), liability insurer, or no-fault insurer.