04/03/2025 | Press release | Distributed by Public on 04/04/2025 12:19
On March 27, 2025, the Centers for Medicare and Medicaid Services (CMS) held an "Introduction to MSP for Beneficiary Representatives Webinar." As part of its webinar announcement, CMS noted that the intent of this webinar was "to support the attorney and beneficiary representative communities and review the basics of MSP, Group Health vs. Non-Group Health Coordination of Benefits, and MSP recovery."i
Overall, CMS focused primarily on Medicare conditional payment recovery issues from the claimant/beneficiary (and their representative) perspective regarding NGHP claims. As outlined below, CMS addressed such issues as how its conditional payment process works, how to dispute CMS's recovery claim, and the use of the Medicare Secondary Payer Recovery Portal (MSPRP). Of note, CMS did not discuss MSP compliance issues or its recovery process from the insurer or primary payer perspective as part of this webinar session.
The authors attended this webinar and provide the following general overview of the key points discussed by CMS related to NGHP compliance matters as follows:
CMS began the webinar with a brief overview of common MSP terms and Medicare's Coordination of Benefits (COB) processes but noted the webinar would be primarily focused on non-group health plan (NGHP) recovery (which, as noted above, is the focus of this summary).
In this regard, CMS noted that NGHPs include liability insurers (including self-insured entities), no-fault insurers, and workers' compensation entities. CMS further noted that as the webinar was intended as an introduction for attorneys and other Medicare beneficiary representatives, the session would focus mainly on Medicare's Benefits Coordination and Recovery Center (BCRC), which is the contractor that handles Medicare conditional payments when recovery is sought from the claimant/Medicare beneficiary. CMS indicated that while its other contractor, the Commercial Repayment Center (CRC), handles conditional payment recovery against group health plans (GHPs) and NGHP insurers, it is possible that CMS may also send correspondence to claimants/beneficiaries and their representatives, although, in general, these parties typically do not interact with the CRC.
CMS recommended that when a claimant/beneficiary suffers an injury or illness for which another primary payer may have responsibility for medical treatment, he/she, or their representative, should report the claim to Medicare to initiate the conditional payment process. Claims can be reported to the BCRC by phone, fax, mail, or the MSPRP and, once a case is created, a Rights and Responsibilities (RAR) letter would be issued to the claimant within 15 days. For a more detailed overview of the MSP recovery process, please see CMS' website.
CMS discussed its various authorizations related to its recovery process and noted that neither CMS nor its contractors can share personally identifiable information (PII) or personal health information (PHI) without proper authorization. Accordingly, CMS noted that it recognizes two types of authorizations for BCRC recovery against the claimant/beneficiary as follows:
Further information on this topic can be found on CMS' website.
CMS then provided a general overview of the different types of conditional payment correspondence issued by the BCRC as part of its recovery activities as follows:
Additional detail regarding BCRC recovery can be found on CMS' website.
CMS noted that there may be instances where CMS's recovery efforts can be challenged by the parties and that there are dispute and appeals processes that are available to claimants/beneficiaries and their authorized representatives. For example, CMS indicated that if a claimant/beneficiary or their representative believes that treatment listed on a CPL or CPN is unrelated to the claim, a dispute can be submitted by the parties outlining what treatment is being disputed and including any relevant supporting documentation. CMS also stated that the BCRC would provide a response within 45 days.
Once a demand is issued, CMS noted that there is a formal appeals process which allows claimants/beneficiaries and their representatives to appeal the existence of the debt and the amount of the debt. CMS stated that the parties must start at the first level of appeal and work their way through the various levels of appeals sequentially, ensuring they are meeting all filing requirements, including any applicable timeframes. For additional information regarding appeals, please see CMS's website.
CMS noted that, in addition to the formal appeals process, claimants/beneficiaries may request that CMS waive or compromise their recovery. On this point, CMS stated that if a request that Medicare waive recovery of the demand in full of in part is received, the BCRC would issue SSA form 632 to the claimant requesting additional information (such as the claimant assets, income, expenses, and reasons why the waiver should be granted) to allow review of the waiver. If the BCRC is unable to grant a request for a waiver, a decision will be issued including appeal options. In addition, CMS stated that compromise requests, where a party is requesting that Medicare accept less than the amount owed, are handled by CMS directly, potentially in consultation with the Department of Justice for higher-value debts. More detail about waiver requests can be found at CMS's website.
Throughout the webinar, CMS made several references to the use and functionality of the MSPRP, CMS's web-based tool designed to assist in the resolution of NGHP recovery cases. On this topic, CMS noted that Medicare beneficiaries can access the MSPRP through their medicare.gov account and that attorneys can register for access through the MSPRP directly. Depending on authorization and case status, users of the MSPRP may be able to take several different actions on a case, including:
Further information about the MSPRP can be found on CMS's website.
At the conclusion of the presentation, CMS indicated that additional resources regarding MSP, NGHP recovery, and the MSPRP can be found at CMS's website. Additionally, CMS stated that the presentation would be posted to CMS's website within the coming weeks. The reader should monitor CMS's website to determine when CMS posts its presentation.
Please do not hesitate to contact the authors if you have any questions regarding the above or how Verisk can help you address MSP compliance issues.