MSA and the Joys of Conditional Payments


As part and parcel of the overall MSA process there is an item called Conditional Payments. When the Medicare Secondary Payer Act went into effect 1980, there was language in the Act which provided repayment to Medicare anytime a payment was made for treatment relating to an injury where another party was responsible. The idea being that any time there’s a work comp claim, a liability claim, or a group health policy that the party responsible for paying those costs should reimburse Medicare if they had mistakenly made payments on a claim. Sounds simple doesn’t it? Like all good things, the reality of this process is anything but straightforward.

Currently, all Insurer’s on a quarterly basis have to let Medicare know of any claims on their books that involve a Medicare beneficiary where they have either the ongoing responsibility to pay for medical treatment or where they’ve settled the claim and the responsibility for future medical care has been transferred to the claimant. Theoretically, Medicare should use the data supplied by the Insurer’sto make sure they don’t make payments on any claim where the carrier has ongoing responsibility for medical care. Again, if only life were that simple.

Unfortunately, Medicare’s record keeping is somewhat questionable and there are numerous instances where they’ve made payments to providers when they shouldn’t. This is where the Conditional Payment process begins.

About a year ago, Medicare contracted with a third-party vendor called the Commercial Repayment Center (CRC) to recoup any payments made while the claim is still active. There’s also another vendor called the Benefits Coordination and Recovery Center (BCRC) who deals with repayments once the claim is closed. The problem is the CRC and the BCRC don’t talk to each other. Frequently, both vendors are trying to capture the same repayment, thus leading to massive confusion and bureaucratic delay for the Insurer.

On November 17th 2016, Medicare held a town-hall call to both go over the current state of the Conditional Payment process and to advise on new developments.  The primary highlights of the call were as follows:

  • There is a backlog at the CRC and requests are being processed in the order in which they are received (supposedly the backlog was remedied in October 2016; however, we are still experiencing significant delays)
  • Improvements to the online Conditional Payment portal are being made with changes going into effect in 2017, 2018 and 2019
  • As of 2017, we will be able to review the accounts receivable information via the portal along with the status of redetermination requests
  • CRC has developed an improved grouping logic for the identification of Conditional Payments to weed out "unrelated" claims for treatment which are not related to the injury (this has not been our experience, we still see Medicare wanting repayment for diagnosis codes completely unrelated to the industrially injury)
  • It is very important when reporting information to Medicare to be specific and accurate as possible in regard to the ICD9/ICD10 codes.  Incorrect diagnosis codes or being too vague in the diagnosis can cause problems for the CRC and the debtor overall
  • Submit Letters of Authority (LOA) to either the CRC or BCRC early in the process so that the case has time to develop (after a case has been reported).  This way, the LOA essentially has "somewhere to go"
  • Rarely, a case will be open at the CRC/BCRC the same time. If this happens, call the BCRC and speak to a recovery specialist to resolve (we see this happening on a regular basis)
  • An asterisk in the portal means reviewed not resolved

The preferred method of correspondence for both the BCRC and CRC is through the online portal.  Unfortunately, the portal can be a very unreliable source of information.  If one number or letter is off from what Medicare has recorded, you may unable to locate a case or any specific details. This causes great confusion because it may seem like a case has not yet been reported, when in fact Medicare is well down the road in its collection efforts. The most tried and true way to communicate with both entities is via fax and phone call. Faxing documentation works well for us, because we receive a transmittal as confirmation our documents were received by Medicare’s vendor. Being able to call and speak directly with a representative about specific cases makes it easy and fast to get answers quickly. The issue we run into using faxes and phone calls is inconsistency in the information being provided by the vendors. At times, documentation is “lost” or has been mis-categorized when sent via fax. Also, there is a limit to how many cases one can follow up on at a time (only 5 or up to one hour of discussion).

As improvements are made to the current portal, we are hoping we can utilize it as a more reliable source of communication to make this process as painless as possible. EK Health will of course continue to monitor this process closely. Our primary goal being to help navigate our client’s through this process as efficiently as possible.


Jake Reason, Vice President of MSA Services