The Commercial Repayment Center (CRC) process was front and center at the November 17, 2016 CMS Town Hall Teleconference. After CMS updated listeners listened to information about the Medicare Secondary Payer Recovery Portal (MSPRP) and Social Security Number Removal Initiative (SSNRI), the CRC had the opportunity to present on lessons learned over the last year. Although it was clear that the process has improved regarding the accuracy of the conditional payments, the backlog remains an issue. The CRC discussed the perceived delays on lead development and explained that when they receive Mandatory Insurer Reporting (MIR), they must validate that all required information is in the report and missing or incorrect information is the primary cause for delay.
The CRC shared timeframes within which each step of the process is currently worked, the reality is that cases are taking longer. The published timelines include:
- Validating the Recovery Agent Authorization or Letter of Authority – 45 days
- Responding to a Conditional Payment Notice Dispute – 30 days
- Responding to a Conditional Payment Letter Dispute – 45 days
- Responding to an Appeal or Communication Post Demand – 60 days
- Responding to Payment – 20 days
Because the CRC prefers to deal with cases referred to them through the MIR process, they generally will close the duplicate self-referred cases, or cases called in by the beneficiary, his or her attorney, the Applicable Plan (AP), or AP’s agent. When closing the duplicate self-referred case, the CRC does not generally transfer any of the items that the parties may have sent in on the self-referred case over to the remaining open case. This often requires parties to resubmit authorization forms, medical records, legal pleadings, settlement documentation, and policy exhaustion proof. Sometimes, more than once. Inevitably, this slows down the CRC process.
Intent to Refer Letters
Another area of concern that was mentioned during the 11/17/16 Town Hall meeting is the continual development of a more defined process to handle the timely response to appeals and the resulting Intent to Refer (ITR) letters. There is currently an overlap in these two processes. Even when the CRC receives a response or appeal to a Final Demand letter from APs or their agents within the prescribed timeframe, an ITR letter will be sent 120 days from the date of the Final Demand even if the CRC has received an appeal but has not yet addressed it. The ITR can confuse APs and their agents and send a misleading message that 1) they missed the appeal deadline or 2) the appeal was not successful or deemed invalid, when in reality, the CRC has received the appeal in a timely manner and just hasn’t had the opportunity to review it and respond. The CRC explained that the ITR will be sent but the file will not actually be sent to the Department of Treasury until any and all disputes or appeals are processed.
Lastly, the CRC indicated that it is sending out closure letters specific to situations in which they have received payment on a Final Demand. However, APs do not receive any clear closure documentation in cases when ORM has been terminated and the AP did not pay because 1) limits were exhausted 2) the time frame for paying bills has expired or 3) Medicare had not paid any bills related to the claim.
October 5, 2016 was the one year anniversary of the CRC pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity, where they are identified as the debtor. Having worked with different recovery contractors over the past several years, most anticipated a period of transition while the CRC refined their processes. Because of the volume, the ongoing nature of ORM, and the potential for MIR mistakes with ORM and ICD codes, most expected the CRC to experience some challenges early on. After a full year, most also expected the CRC process to be pretty clear and running smoothly. Unfortunately, there are still lots of questions surrounding some of the processes and communications that need to be ironed out.
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