CMS Issues NGHP Secondary Payer Reference Guide for Beneficiaries
by P. Czuprynski
The Centers for Medicare & Medicare Services (CMS) has released version 1.0 of its Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) Beneficiary Reference Guide pertaining to Medicare Secondary Payer recovery based on workers compensation, no-fault and liability claims.
In the guide, Medicare details the process for seeking reimbursement for conditional payments and avenues of appeal that may be available to a beneficiary for their claim. The guide provides an excellent road map for beneficiaries to understand why and when Medicare may seek reimbursement for conditional payments.
Carriers/self-insureds and their TPAs can also use this reference guide for situations when they are anticipating a negotiation or have agreed to negotiate and reimburse conditional payments found based on a reported settlement. In these circumstances, the carrier/self-insured may need to obtain the Proof of Representation to dispute or negotiate conditional payments. When detailing the collection process for a settlement, judgement or award, Medicare provides details about the Commercial Repayment Center (CRC) collections process based on Ongoing Responsibility for Medical (ORM) reporting.
Hopefully, the reference guide can help beneficiaries identify situations where this bifurcated process is happening on their claim. If ORM is indicated, the CRC may conduct multiple searches and seek reimbursement directly from the carrier/self-insured. However, once settlement is reported, the Benefits Coordination & Recovery Center (BCRC) completes a final sweep for conditional payments and if charges are found, Medicare may look to the beneficiary for reimbursement.
IMPAXX uses the appeal and negotiation processes detailed in the reference guide as a part of our comprehensive conditional payment negotiation services. If you have any questions about the reference guide or would like to learn more about our conditional payment services, please contact us at [email protected].