News

Progress in Conditional Payments

Sunday, July 15, 2018

With more than half of 2018 on the books, it’s a good time to check in on Medicare’s conditional payment process. There are a number of changes to Medicare’s conditional payment program that had an impact on day-to-day claims handling – mostly for the better.  Here’s a recap of some of the key changes that we have seen this year.

Updated Conditional Payment Portal

A number of noteworthy changes have been made to Medicare’s conditional payment web portal.  The portal allows users to perform a variety of different activities on conditional payment claims, including filing disputes, uploading documents, and obtaining status updates.  CMS and its contractors are updating the portal more frequently.  In February, the portal was updated to provide status updates on disputes and appeals filed recently.  Two key updates make the portal significantly more useful.

  • eCPL – For the first time, authorized (and authenticated) conditional payment portal users may now download an electronic conditional payment letter.  The electronic conditional payment letter (referred to as an “eCPL”), allows users to download a PDF of a conditional payment letter in real-time.  This can be incredibly useful in a number of situations – most notably in circumstances where a conditional payment letter is sought to secure approval of a workers’ compensation settlement.
  • Status updates ­– Medicare’s portal also includes real-time updates regarding the status of correspondence, including disputes, and appeals.  This useful new feature allows users to obtain information directly from the portal rather than follow up via telephone. 

The portal is still not perfect.  Electronic CPLs are not available on all cases and it can be challenging to gain access to these features on all possible cases.  In some cases, access is not granted properly to authenticated users.  However, these improvements do make the conditional payment process more efficient.  As regular users of the portal, ExamWorks Clinical Solutions applauds CMS and its contractors for making these changes.  

Observations on the New Commercial Repayment Contractor (CRC)

Performant Financial assumed the role as Medicare’s CRC in February, taking over for CGI Federal.  We wrote about the contractor transition here and here.  The prior contractor left an absolute mess for Performant to clean up.  Disputes and appeals filed by insurers and Medicare compliance organizations were left unworked; faxed and mailed disputes and appeals were “lost” or incompetently logged, leading to improper dismissal; and a stack of thousands of requests for information was left untouched, leading to a tremendous volume of cases where parties simply were waiting for conditional payment information. Into this breach, Performant has compartmentalized its priorities as the new contractor, and it emphasized clearing a backlog of unresolved conditional payment disputes and appeals that had accumulated under CGI’s oversight. 

As Performant has spent energy on resolving the backlog, fewer new conditional payment notices and demands have issued.  Over the course of the last several weeks, it seems that Performant / CRC is issuing more and more unsolicited conditional payment letters.  As they issue these letters, it’s important to review any conditional payment letters carefully, and ensure that they are vetted properly.  ExamWorks Clinical Solutions is following this transition closely and will continue to provide critical updates as changes are made.

U.S. Department of Treasury Situation

Since about January 2017, Medicare and its contractors have referred matters aggressively to the Department of Treasury for direct collection and offset.  As Performant began to work through the tremendous backlog of cases that CGI left behind, debts were referred to the Treasury Department as soon as the appeal was reviewed, and direct offset occurred nearly as quickly.  Often the Treasury Department took funds from entities caught completely unaware that an appeal was unsuccessful or only partially favorable.  For many, this was a confusing fiasco.  A tremendous amount of these offsets occurred improperly, and refunds are due.

This is perhaps not all that surprising.  Medicare’s Annual Report on the CRC program for FY 2017 outlined Treasury Department recoveries over $30 million in Medicare Secondary Payer payments on behalf of the CRC.   Over that same period, the CRC refunded over $22 million in excess recoveries.  FY 2017 ended on September 30, 2017.  While not all of those recoveries occurred due to Treasury offsets, it’s worth marking those numbers for comparison when FY 2018’s report is released next year.

Conclusion

ExamWorks Clinical Solutions has been closely watching these issues.  We will continue to post regular updates as additional information is provide. Contact Lou Porrazzo about the Commercial Repayment Center and compliance solutions to these thorny issues. 

About Marty Cassavoy 

Marty Cassavoy is the Vice President of MSP Compliance at ExamWorks Clinical Solutions.  Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer compliance and across all insurance types.  An attorney licensed to practice law in Massachusetts, Marty works in ExamWorks’ Woburn, Massachusetts office and can be reached at 781-517-8085 or marty.cassavoy@examworks-cs.com

About Lou Porrazzo 

Lou Porrazzo is the Director of Conditional Payment Research at ExamWorks Clinical Solutions.  Lou manages our conditional payment research department, and oversees overall conditional payment and Treasury investigations, disputes, and appeals program.  An attorney licensed to practice law in Massachusetts, Lou can be reached at louis.porrazzo@examworks-cs.com or 678-256-5085.