Medicare Secondary Payer (MSP)
Liability Insurance, No-Fault Insurance &
Workers’ Compensation Recovery
Process
Note: This presentation is intended for Medicare
beneficiaries and their representatives.
Topics
• Medicare’s Right of Recovery;
• Overview of the Recovery Process;
• When to contact the Benefits Coordination &
Recovery Center (BCRC);
• The Rights and Responsibilities Letter;
• The difference between Proof of Representation
and Consent to Release;
• What "Proof of Representation" documentation
is required for representatives and their agents;
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Topics (continued)
• The conditional payment letter process and
timeline;
• What to provide the BCRC when there is a
se
ttlement, judgment, award, or other
payment;
• The recovery demand letter process and
time
line; and actions subsequent to the
demand letter.
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Medicare’s Right of Recovery
Non-Group Health Plan (NGHP)
• This document refers to Liability Insurance (Including Self-Ins
urance), No-
Fault Insurance, and Workers’ Compensation collectively as Non-Group
Health Plan or NGHP.
• The applicable statute is 42 U.S.C. 1395y(b). See particularly, 42 U.S.C.
1395y(b)(2
)(A)&(B). See also 42 CFR Part 411 for the applicable
regulations.
• Medicare is secondary to all types of liability insurance, no-fa
ult insurance,
or workers’ compensation. Note: For liability insurance, this includes self-
insurance which is defined by statute as follows: “An entity that engages in
a business, trade, or profession shall be deemed to have a self-insured
plan if it carries its own risk (whether by a failure to obtain insurance, or
otherwise) in whole or in part.”
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Medicare’s Right of Recovery
(continued)
Non-Group Health Plan (NGHP)
• Medicare may make conditional payments while a NGHP claim is
pen
ding but is entitled to repayment. “A primary plan, and an entity
that receives payment from a primary plan, shall reimburse the
appropriate Trust Fund for any payment made by the Secretary
under this title with respect to an item or service if it is
demonstrated that such primary plan has or had a responsibility to
make payment with respect to such item or service. A primary
plan's responsibility for such payment may be demonstrated by a
judgment, a payment conditioned upon the recipient's
compromise, waiver, or release (whether or not there is a
determination or admission of liability) of payment for items or
services included in a claim against the primary plan or the primary
plan's insured, or by other means.”
5
Overview of the Recovery
Process
• The Benefits Coordination & Recovery Center (BCRC)
is responsible for ensuring that Medicare gets repaid
by the beneficiary for any conditional payments it
makes. The “Beneficiary NGHP Recovery Process
Flowchart” provides the typical steps involved in
recovering conditional payments from the Medicare
beneficiary. This document can be accessed by
clicking the
Attorney Services link.
6
BCRC Roles & Responsibilities
for NGHP
The BCRC:
• Is responsible for the collection and maintenance of the
MSP
information in CMS’ systems.
• Develops and researches MSP occurrences, as appropriate.
(Sou
rces include: Identification of a pending NGHP claim
by a beneficiary or his or her attorney or other
representative, by an insurer or other entity, through
claims processing information, etc. Identification may also
occur through MMSEA Section 111 reporting.)
• Updates data in CMS’ systems regarding MSP occurrences
(t
erminations, changes in effective dates, address changes,
etc.).
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Contacting the BCRC in
Pending NGHP Cases
Contacting the BCRC is always the first step for interacting with
Medicare if you have a pending NGHP claim. The BCRC needs the
information below to get started:
• Beneficiary Information
– Name
– Medicare Number
– Gender & Date of Birth
– Complete Address & Phone number
• Case Information
– Date of Incident (DOI): Date of injury/accident, date of first exposure
or ingestion, date of implant.
– Description of alleged injury or illness; description of alleged harm.
– Type of Claim (liability insurance [including self-i
ns
urance], no-fault
insurance, workers’ compensation).
– Insurer/workers’ compensation entity name & address.
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Contacting the BCRC in Pending
NGHP Cases (continued)
• Representative Information
– Attorney or other representative name
– Law Firm name if the representative is an attorney
– Address and phone number
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Contacting the BCRC
By Telephone
BCRC Call Center:
1-855-798-2627
1-855-797-2627 (TTY/TDD)
Hours of Operation: Monday – Friday 8 a.m. - 8 p.m. ET
By Mail - General Inquiries
MEDICARE – MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897
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Rights and Responsibilities
Letter
• Once the BCRC establishes an NGHP MSP occurrence in CMS’
systems, a case is established in the BCRC’s recovery system, and
the BCRC will issue a “Rights and Responsibilities Letter.”
Note: If Medicare is pursuing recovery directly from the insurer/workers’
compensation entity, the beneficiary and beneficiary’s attorney or other
representative will receive a copy of recovery correspondence sent to the
insurer/workers’ compensation entity.
• The Rights and Responsibility (RAR) letter is mailed to all
appropriate individuals/entities associated with the case and is
accompanied by:
– A correspondence coversheet
– An educational brochure
– A Privacy Act enclosure
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Claim Retrieval Process
• The BCRC begins retrieving all claims paid by Medicare with dates
of service on or after the Date of Incident. Once the BCRC receives
this information, the claims are reviewed to determine which
services are related to the NGHP claim.
• The BCRC is not able to provide the Conditional Payment
inf
ormation until the claim information has been reviewed.
• Send the Proof of Representation (POR) or Consent to Release
(C
TR), as appropriate, to the BCRC as soon as possible.
• If no valid POR or CTR document has been received by the BCRC,
the
Conditional Payment Letter (CPL) will ONLY be sent to the
beneficiary and any no-fault insurer or workers’ compensation
entity reflected in the BCRC’s records.
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Proof of Representation vs.
Consent to Release
Documentation requirements for a wider array of POR or CTR situations can
be found in the ”POR vs. CTR” presentation. This document can be accessed
by clicking the
Medicare’s Recovery Process link. The presentation includes:
• Beneficiary non-attor
ney representatives.
• Beneficiary attorney representatives.
• Beneficiary guardians, conservators, power of attorney, Medicare
r
ep
resentative payees.
• Situations where the beneficiary’s representative (representative payee,
co
nservator, guardian, power of attorney) has hired an attorney or the
beneficiary attorney has referred the case to another attorney.
• Deceased beneficiaries.
• Workers’ compensation or no-f
a
ult insurance vs. liability insurance
(including self-insurance).
• Agents for insurers or workers’ compensation carriers.
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Other Resources
For purposes of this presentation, we will be focusing on the
documentation required if you are an attorney representing a
beneficiary, including if you are using an agent to assist you in
resolving any potential Medicare claim recovery. However, you
should take the time to review the full “POR vs. CTR”
presentation for other issues.
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Consent to Release
• The beneficiary has authorized an individual or entity
to receive certain information from the BCRC for a
limited period of time.
• The Consent to Release does NOT give the individual or
entity the authority to act on behalf of the beneficiary.
• The Consent to Release does NOT give the individual or
entity receiving beneficiary information the right to
further release that information.
• The exchange of information is like a one-way street
(i.e., the flow of information goes only from the BCRC
to the individual or entity the beneficiary has
authorized on the consent to release).
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Proof of Representation
• The beneficiary has authorized the individual or entity (including an
attorney) to ACT on the beneficiary’s behalf.
• The attorney or other representative may receive and/or submit
in
formation/requests on behalf of the beneficiary including:
– Responding to requests from the BCRC
– Disputing unrelated claims on conditional payment letters
– Correcting case-r
e
lated information (e.g., date of incident)
– Filing an appeal (if appropriate) or filing a request for waiver of
re
covery (if appropriate)
• The exchange of information is like a two-way street (i.e.,
information can be exchanged between the BCRC and the attorney
or other representative that the beneficiary has authorized to act
on their behalf).
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Proof of Representation Requirements –
Beneficiary Attorney Representative
• Attorneys representing beneficiaries may submit their
retainer agreement with the beneficiary if:
– The retainer agreement is on attorney letterhead or
accompanied by a cover note on letterhead,
– The retainer agreement is signed by the beneficiary,
– The beneficiary’s name and Medicare Number are printed at
th
e top of the form (this may be added after the retainer
agreement is signed)
– The retainer agreement is signed or countersigned and dated
by t
he attorney.
• Attorneys representing beneficiaries may also provide the
same proof of representation as non-attorneys if they wish
to do so.
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Proof of Representation Requirements –
Beneficiary Attorney Representative
(continued)
• Attorney representing beneficiary refers a matter to another
attorney: The second attorney must have a letter from the first
attorney showing his/her association on the beneficiary’s claim and
the necessary proof of representation document or retainer
agreement from the beneficiary to the first attorney.
• Attorney representing beneficiary hires an agent to resolve
Me
dicare’s potential recovery claim: The agent must have a
beneficiary specific letter from the attorney specifying that the
agent has been hired to resolve Medicare’s potential recovery
claim and the necessary proof of representation document or
retainer agreement from the beneficiary to the attorney.
• In other words, you must have an appropriate chain of
au
thorization. We need to be able to link the beneficiary to you.
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“Proof of Representation” and “Consent
to Release” Model Language
• Model language for “proof of representation”
an
d “consent to release” can be accessed by
clicking the
Medicare’s Recovery Process link.
• Individuals/entities are not required to use
this
model language but must provide all of
the information requested in the model
language.
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Conditional Payment Letter (CPL)
• A “Conditional Payment Letter” or “CPL” provides
information on items or services the BCRC has
identified as being related to the pending NGHP claim.
The conditional payment amount is an interim
amount. Medicare may continue to make conditional
payments while a matter is pending. Consequently, the
BCRC cannot provide a final conditional payment
amount until there is a settlement or other resolution.
• An initial CPL will be issued to all authorized
individuals/entities within 65 days of the date of the
Rights and Responsibilities Letter. Additional requests
for a CPL will not expedite the process for the initial
CPL.
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Conditional Payment Letter (CPL)
(continued)
• If the BCRC does not timely receive proof of representation
for the beneficiary or information concerning the no-fault
insurer or workers’ compensation, the initial CPL will be
issued solely to the beneficiary. The most expedient way for
the beneficiary’s attorney or other representative to obtain
a copy of the CPL in this situation is to request a copy from
the beneficiary.
• Review the Conditional Payment Letter thoroughly to
ens
ure all case-related claims are included.
• Updated conditional payment amounts will appear
aut
omatically on the beneficiary’s MyMedicare.gov record.
(An attorney or other representative can only obtain access
through his/her client.)
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Notice of Settlement, Judgment,
Award, or Other Payment
• Once case has settled, appropriate documentation must be
furnished to the BCRC. Required information includes:
– Date of Settlement, Judgment, Award, or Other Payment Amount
– Attorney’s fees (borne by the beneficiary)
– Other procurement costs borne by the beneficiary (itemized)
– In some instances a copy of the settlement/judgment/award will be
r
e
quested as well as a copy of the release signed in connection with
the settlement, judgment, award or other payment.
• The BCRC takes attorney fees and other procurement costs borne
by the beneficiary into account when computing a final demand
amount (see 42 CFR 411.37). Note: If the beneficiary’s
representative hires another individual or entity to resolve any
Medicare recovery claim, this fee may not be included in the
procurement cost. This is not a cost incurred to obtain the
settlement, judgment, award or other payment.
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Final Demand Letter
• Once appropriate documentation concerning
a s
ettlement, judgment, award, or other
payment is received by the BCRC, a final
demand letter is generated.
• Payment is due within 60 days of the date of
the
demand letter.
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Final Demand Letter Interest
• Interest accrues from the date of the demand
let
ter and will be assessed on the outstanding
balance on day 61 if no payment is received
within 60 days of the date of the demand
letter.
• Payment is applied to interest first, principal
se
cond. Requests for appeal or waiver of
recovery do not stop the accrual of interest.
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Delinquency, Referral to Treasury
• The debtor is notified of delinquency through an Intent to Refer
Letter (a “Notice of Intent to refer Debt to the Department of the
Treasury or a Treasury Designated Debt Collection Center for Cross-
Servicing and Offset of Federal Payments”), which provides 60 days
for a response resolving the debt.
• If full repayment or Valid Documented Defense is not received
wit
hin 60 days of Intent to Refer Letter (150 days of Demand
Letter), debt is referred to Treasury once any outstanding
correspondence is worked.
• Once debt is referred to Treasury, all correspondence must be
di
rected to Treasury not the BCRC.
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Repaying Medicare
• When sending payment, please make checks payable
to “Medicare.”
• Please ensure that the following information is
included either on the check or on an attached
remittance:
– Beneficiary's Name
– Beneficiary's Medicare Number
– Type of Case
– Date of Injury
• If the check is also payable to any parties other than
Medicare, please ensure the check is fully endorsed
prior to sending it to the BCRC.
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BCRC Contact Information
Normal contact process:
• Call our call center at 1-85
5-798-2627 during our
operating hours 8 a.m. – 8 p.m., Monday – Friday,
Eastern time.
• Please have the beneficiary’s Medicare Number
wh
en calling the BCRC.
• Please include the Medicare Number and date of
inc
ident on all correspondence mailed or faxed to
the BCRC.
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MyMedicare.gov
• See the MyMedicare.gov site for further information.
• Beneficiaries can view various types of information on this
sit
e. (Attorneys or other representatives can only obtain
access through the beneficiary they represent.)
• Where the BCRC has established a potential NGHP
rec
overy case, once it has retrieved claims and reviewed
them to determine which are related to the pending NGHP
claim, this information will be available on an MSP TAB for
that particular beneficiary. The information will be updated
as the BCRC updates its information.
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