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MSPN Annual Conference Recap

October 18, 2024
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Medicare written on Chalkboard in white chalk with a red stethoscope resting on top of the chalkboard on the right side

By M. Heberling and D. Dietz

The National MSP Network held their annual educational conference on September 25-27. This was an exciting year to be at the conference as there have been many new developments in the Medicare Secondary Payer (MSP) space. This includes the impending Civil Money Penalties (CMPs), upcoming expanded Total Payment Obligation to Claimant (TPOC) reporting, and potential industry impact of the Supreme Court Decisions in Loper Bright Enterprises v. Raimondo. IMPAXX has previously written blogs on these topics.

Every year a highlight of the conference are sessions with representatives from the Centers for Medicare & Medicaid Services (CMS) including the Workers’ Compensation Review Contractor (WCRC), Commercial Repayment Center (CRC), and Benefits Coordination & Recovery Center (BCRC). In this recap, we want to provide notable and interesting information shared by these representatives during the conference.

News and Notes

    • CMS is considering eliminating reviews/approvals of zero-dollar MSAs. While this process currently remains the same, CMS will post specific information on any policy changes in the future. However, they plan to discuss their proposed changes with the MSPN Board prior to announcing any policy changes.
    • CMS is confident in their policies and procedures and does not have plans to make any changes in response to the Supreme Court decisions in the Loper Bright or Relentless, Inc. v. Department of Commerce. CMS has no current plans to react to these decisions at all.
    • There are no plans to change the workload review threshold for the CMS submission process.
    • CMS was once again clear that submission of Medicare Set-Asides (MSAs) for review is a voluntary process. CMS indicated that there is no need for a formal appeals process because submission itself is voluntary.
    • CMS noted that expanded TPOC reporting requirements are intended to benefit the Insurer because they helps ensure that settlement funds are being used for their intended purpose.
    • Expanded TPOC reporting will require an MSA amount to be reported on all settlements with a Medicare beneficiary. This is the case even if the TPOC is below the $25,000 threshold for CMS submission (even if the MSA amount being reported is $0).
    • CMS discussed performing an audit of a beneficiary’s exhaustion of an MSA in situations where the funds were depleted significantly faster than anticipated at the time of settlement. The initial focus would be on determining if the funds were used properly by the injured party rather than whether the MSA was sufficiently funded.
    • CMS will be sending more letters and information to Medicare beneficiaries after the implementation of the expanded TPOC reporting changes in April 2025. Beneficiaries will be directed to reach out to the appropriate CMS regional office. CMS will also be sending beneficiaries attestation letters based on Section 111 and TPOC reporting data.
    • There are no plans to use the ratio of reported TPOC amount to reported MSA amount as a basis (or as any part of the analysis) for an audit.
    • CMS is looking into providing an escalation process at the BCRC, similar to the process used at the CRC.
    • CMS stated that 83% of MSAs are approved as submitted, whereas 30% of MSA submissions require record development prior to approval. CMS indicated the turnaround time for Re-Review and Amended Review submissions should be under 10 days.
    • CMS does not give weight to the current opinion of a treating medical provider if they have not seen the patient within the last 2 years. If the claimant has not been back to the doctor, CMS is recommending they re-establish treatment with the authorized doctor.
    • A CMS review program for Liability MSAs will require a formal rule-making process, which is not in the works at this time.
    • CMS indicated that artificial intelligence (AI) is currently being used in their call center. There is a pilot program with Allstate to use AI/Machine Learning in the conditional payment and lien identification process with the CRC. There were no current plans however, to use AI as part of CMS’ WCMSA review program.

Tips and Takeaways

Based on the above information, IMPAXX recommends that our customers continue to examine their policies regarding when (or even if) to engage in the voluntary WCMSA review process. This includes situations that would be considered below the review threshold and not eligible for submission. Keep in mind that in all situations, if a workers’ compensation settlement with a Medicare beneficiary includes funds for future medical, then those medical amounts will need to be specifically reported to CMS along with TPOC data after April 2025.

Additionally, because CMS has indicated their initial focus is on early exhaustion of an MSA, rather than if an MSA was sufficiently funded, then it is advisable for parties – primarily the beneficiary – to be fully aware of their obligations at time of settlement. In order for all parties to feel insulated from future issues, there may be an increasing need for professional administration. Professional administration helps confirm the funds are being used on injury-related, Medicare covered treatment AND offers discounts and services that aid in the preservation of MSA funds.

If you have questions about any news shared at the MSPN conference, or CMS policies in general, please reach out to our Settlement Consulting team at [email protected].