$750 Threshold on Reporting and Conditional Payment Recovery Maintained

In a 11/15/2018 Alert, CMS announced that the 2019 recovery threshold for liability, no-fault and workers’ compensation settlements will remain at $750. Accordingly, Total Payment Obligations to the Claimant, TPOCs, in the amount of $750 or less are not required to be reported to CMS through the Section 111 Mandatory Reporting process, nor will CMS attempt to recover conditional payments for TPOCs of this amount.

By way of background, pursuant to the SMART Act of 2012, CMS is required to annually determine a threshold amount such that the cost of collection does not outstrip the amount recovered through such collection efforts. CMS’s calculations, which can be found here, resulted in the $750 threshold being maintained.

Upcoming Webinar on MSPRP Self-Reporting Enhancement

CMS also recently announced it will hold a webinar on 12/18/2018 at 1 p.m. ET to provide an overview of the self-reporting functionality that will be added to the Medicare Secondary Payer Recovery Portal (MSPRP) as of 1/7/2019. The webinar invite can be found here.

Self-reporting refers to reporting a no-fault, workers’ compensation or liability claim to CMS’s Benefits Coordination and Recovery Center (BCRC) which is typically the first step in identifying whether conditional payments have been made by Medicare in the claim. Presently, reporting can be done via phone, fax, mail or through the Section 111 mandatory insurer reporting process.

The so-called “lead” which results from this reporting is utilized by CMS’s recovery contractors, the BCRC or the Commercial Repayment Center (CRC) to investigate payments made by Medicare for the reported diagnosis and seek recovery for conditional payments made for the diagnosis. It is anticipated the expansion of self-reporting to the MSPRP will assist in expediting the Medicare conditional payment investigation process and perhaps improve the accuracy of charges identified as conditional payments.

Practical Implications

As CMS is keeping the $750 threshold for mandatory reporting and conditional payment recovery there are no changes to the reporting processes or determinations as to when conditional payment should be investigated or resolved.

In regard to the self-reporting enhancement to the MSPRP, as noted above, we believe this may improve the speed and accuracy of the Medicare conditional payment process. We will provide further information following the December 18 webinar.