On March 27, 2025, The Centers for Medicare & Medicaid Services (CMS) hosted a webinar on the Introduction to MSP for Beneficiary Representatives. The intent of the
webinar was to support the attorney and beneficiary representative communities and review the basics of MSP, Group Health vs. Non-Group Health Coordination of Benefits, and MSP recovery.
Navigating conditional payments can be complicated, especially for injured workers that are not represented. It’s crucial to understand the time-sensitive recovery process to preserve rights and dispute unrelated charges. CMS provided the background on Non-Group Health Plans (NGHP) Medicare Secondary Payer (MSP), Coordination of Benefits (COB) and Medicare’s right of recovery. CMS webinar was limited to Traditional Medicare (Part A – Hospital and Part B – Physician Medical), excluding MedAdvantage and Prescription Drug Plans as they pursue their own recoveries.
What is a Conditional Payment?
Medical bills paid by Medicare in which another primary payer may be responsible. Payment is made “under the condition” that Medicare will be reimbursed if it is determined another primary payer exists and is responsible for the payment.
Medicare’s Right of Recovery
Medicare is permitted by the statute to make a payment on the condition that it is reimbursed once liability for that payment has been established.
- 42 U.S.C. 1395y(b)(2)(B)(i) – authority to make conditional payment and 1395y(b)(2)(B)(ii) – repayment required
Recovery is managed by two contractors:
- Commercial Repayment Center (handles Ongoing Responsibility of Medical) and
- Benefits Coordination & Recovery Center (BCRC) that handles conditional payments once case settles.
- Please refer to the resource link below for each recovery process.
There are 2 types of authorizations that allow the beneficiary representative to obtain conditional payment letters:
- Consent To Release (CTR)– allows for copies of the conditional payment letters to be send to the beneficiary representative; however, they cannot dispute the lien. This is one way communication
- Proof of Representation (POR) – allows beneficiary representative to dispute conditional payments on the beneficiary’s behalf. This provides for two-way communication.
The webinar covered the CRC and BCRC letters, timelines, dispute process, and five level appeal process. It is essential for beneficiary/representative to check the date of service on the conditional payment letters to verify the charges fall within the DOI and the settlement date. It is also important to review and dispute any unrelated charges, discrepancies, or statuses with the carrier while ORM is open, as responsibility shifts to the beneficiary once the case is settled (TPOC).
Conditional Payment Letter (CPL) Workflow:
- Estimate and not Time-Sensitive; letter outlines debt allegedly owed to Medicare
- Conditional Payment Notice (CPN)
- 30 days to informally dispute debt
- Demand Letter (*Formal Appeals Process Triggered, 42 C.F.R. 405.900)
- 60 days to pay without interest; 120 days to appeal before debt is sent to Treasury
- Intent to Refer to Treasury (ITR)
- 65 days post-Demand
- Soft warning that case is approaching 120-day deadline to file an appeal.
- Treasury Notice/PCA Notices
Five Level Appeal Process:
- Redetermination - CRC or BCRC - due 120 Days from the Demand letter date
- Reconsideration via the Qualified Independent Contractor - due 180 days from the QIC Decision date
- ALJ Hearing - Due 60 days from the QIC Decision date
- Medicare Appeals Counsel - Due 60 days from ALJ Decision date
- Federal Court - 60 days from Level 4 Decision date
Injured worker attorney’s/representative can sign up for the Medicare Secondary Payer Recovery Portal (MSPRP). Once the beneficiary representative is authorized, they will be able to access and update The MSPRP gives users (attorneys, beneficiaries) the ability to access/request case specific information and monitor the recovery process online. MSPRP can be used to develop leads, request updates to the lien balance, monitor status of dispute/appeals, Request Demand letters and more.
Post Settlement Insights:
If the Final Demand goes unpaid (180 days from Final Demand), the Intent To Refer (ITR) letter goes out. Delinquent conditional payment debt can take 2 paths after it is referred to the U.S. Treasury:
- Private Collection Agents (PCA): debt is assigned to a collection company for additional recovery efforts.
- Treasury Offset Program (TOPS): debt is registered into database where the government seeks opportunities to offset a financial relationship between debtor and government. Examples of how the government seizes the money owed to them:
- SSDI benefits garnished in delinquent BCRC debt where the beneficiary is the debtor.
The most common mistake with conditional payments is not understanding that there are two recovery contractor models.
- CRC: recovery against the underlying medical coverage (ORM).
- BCRC: recovery against all diagnoses released in settlement (TPOC).
- Don’t assume that a pre-settlement lien search with the CRC indicating a $0.00 balance means there will not be a conditional payment lien when the settlement is finalized. The BCRC will do one final sweep that may catch conditional payments.
Post settlement, BCRC considers the injured worker the debtor of the conditional payment. When a WC claim settles out medical, BCRC will send the conditional payment letters directly to the beneficiary only.
What happens when the WC carrier accepts responsibility of conditional payments in the settlement without the beneficiary authorization?
BCRC sends conditional payment letters directly to beneficiaries, who may assume their carrier will handle payments according to the settlement agreement. However, if the beneficiary does not include the carrier in these communications, the carrier remains unaware of the conditional payment letter. As a result, the debt could be sent to the Treasury, potentially leading to an offset of the beneficiary’s SSDI benefits.
At Ametros, we assist beneficiaries’ post-settlement with professional administration services. We proactively contact injury-related physicians and pharmacies to ensure they bill Ametros for injury-related care that would otherwise be covered by Medicare. This prevents unnecessary denials and potential post-settlement conditional payments from Medicare advantage and prescription drug plans.
If you have any questions about how Ametros simplifies and supports MSA administration and other future medical allocations post-settlement, don’t hesitate to get in touch with us.
Resource Links:
