CMS Alert Warns Worker’s Comp & Other Liability Payers To Comply With Medicare Benefit Coordination Rules 


The Center for Medicare & Medicaid Services (CMS) is responsible  for protecting the Medicare program’s fiscal integrity and ensuring that it pays only for those services that are its responsibility. Medicare Secondary Payer (MSP) provisions make Medicare a secondary payer to certain non-group health plans (NGHPs), which include liability insurers (including self-insured entities), no-fault insurers, and workers’ compensation entities. CMS has the right to recover Medicare payments made that should have been the responsibility of another payer.

MSP situations involving NGHPs are triggered by unexpected incidents, such as car accidents or work-related injuries, involve Medicare beneficiaries, and result in medical expenses for which an NGHP (rather than Medicare) has primary responsibility for payment. In these situations, Medicare becomes a secondary payer. In some MSP situations involving NGHPs, Medicare will initially pay for related medical expenses in order to ensure that the beneficiary has timely access to needed care and later seek to recover those payments.

The CMS Benefits Coordination & Recovery Center (BCRC) seeks repayment  for any conditional payments it makes related to a liability, no-fault, or workers’ compensation case. A conditional payment is a payment Medicare makes for services another payer may be responsible for. The payment is “conditional” because it must be repaid to Medicare when a beneficiary receives a settlement, judgment, award, or other payment from an NGHP.

When the BCRC learns of an NGHP case, it gathers information about any related conditional payments Medicare made and request repayment. 

A beneficiary or beneficiary’s attorney or other representative may contact the BCRC for any of the following questions/issues:
Questions about Medicare’s recovery rights or the reimbursement process

To obtain conditional payment amounts

To obtain Medicare’s final recovery claim amount

Questions regarding MSP recovery demand letters

Questions with respect to a “Notice of Intent to Refer Debt to the Department of Treasury” letter

Questions regarding repaying Medicare

To request a waiver of recovery with respect to a beneficiary MSP debt. (Note: A waiver of recovery request cannot be accepted or processed until a recovery demand letter is issued.)

To request a first level appeal with respect to the determination contained in a beneficiary MSP recovery demand letter or a determination made on a waiver of recovery request from a beneficiary

Please see the Contacts page for specific contact phone numbers and mailing address information.
Commercial Repayment Center (CRC) Responsibilities  
Effective October 5, 2015, the Commercial Repayment Center (CRC) assumed responsibility for the recovery of conditional payments where an insurer/workers’ compensation entity is the identified debtor. Any NGHP recoveries initiated by the BCRC prior to the October 2015 transition will continue to be the responsibility of the BCRC. To view the process of recovering conditional payments from an insurer/workers’ compensation entity, click the Insurer NGHP Recovery link.
When to Contact the CRC
Insurer/workers’ compensation entities should review their recovery letter for a return address or closing referencing the BCRC or CRC. If the CRC sent the letter, contact the CRC. However, if the BCRC sent the letter, contact the BCRC. The insurer/workers’ compensation entity may contact the BCRC or the CRC, depending on who sent their recovery letter, for any of the following questions/issues:
Questions about Medicare’s recovery rights or the reimbursement process

Questions regarding Conditional Payment Letters/Conditional Payment Notices

Questions regarding MSP recovery demand letters

Questions with respect to a “Notice of Intent to Refer Debt to the Department of Treasury” letter

Questions regarding repaying Medicare

To request a first level appeal with respect to the determination contained in an MSP recovery demand letter

Please see the Contacts page for specific contact phone numbers and mailing address information.
Medicare Secondary Payer Recovery Portal (MSPRP)
The MSPRP is a web-based tool designed to assist in the resolution of liability insurance, no-fault insurance, and workers’ compensation Medicare recovery cases. The MSPRP gives users (attorneys, insurers, beneficiaries, and recovery agents) the ability to access and update certain case specific information online and monitor the recovery process online. For additional information regarding the MSPRP, click the Medicare Secondary Payer Recovery Portal link.
Note: NGHP Recovery related materials previously available as downloads on this page have been moved to the Beneficiary or Insurer Services sections of CMS.gov, as applicable. Click the Medicare’s Recovery Process link to access downloads pertinent to the beneficiary. Downloads pertaining to the insurer/workers’ compensation entity may be accessed by clicking the Insurer NGHP Recovery link.

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