Blog

The Benefits Coordination & Recovery Center (BCRC) is responsible for recovering conditional payments made during the course of a workers’ compensation claim when there is a settlement, judgment, award, or other payment made to the Medicare beneficiary.  The Parties, including Beneficiaries and their attorney(s) should recognize the obligation to reimburse Medicare during any settlement negotiations, and determine who will be responsible for paying conditional payments, if any. When there is a settlement, judgment, award, or other payment, the beneficiary, their attorney, carrier, or other representative should notify the BCRC.    The BCRC process may also be (and is often) triggered when an MSA is submitted, approved, and the final settlement documents are received by CMS.      However, if there is an outstanding conditional payment at the time of settlement that is not addressed in the settlement, the beneficiary may be in for a big surprise. If CMS believes conditional payments exist,  and a settlement, judgment, award, or other payment has already occurred when a case is first reported, a Conditional Payment Notification (CPN) will be issued.  A CPN will also be issued when the BCRC is notified of settlement, judgment, award, or other payment through an insurer/workers’ compensation entity’s MMSEA Section 111 report. The CPN provides conditional payment information and advises on what actions must be taken. How can an Applicant be proactive regarding conditional payments?   Make sure CMS is notified as soon as there is a pending liability, no-fault, or workers’ compensation claimParties may obtain a current conditional payment amount periodically throughout the claim to stay on top of any issuesObtain current conditional payment information at the time of settlementClearly identify body parts admitted under claim in the settlement documents.  If needed, a statement that all other body parts/claims are denied.  Please consider jurisdictional requirements regarding settlement languageDo you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?    Contact us for more information! Questions about MSAs,  future medical cost projections/life care plans or posturing your cases for future medical settlement? Click here for more information.Stay tuned for Part VI of our MSA Reporting Series – Settling a case before CMS approves a submitted MSANote:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement,  review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!

As noted earlier in our series, the purpose of reporting such claims to CMS is so that CMS can assure Medicare remains the secondary payer for medical care related to the claim, and recover any applicable conditional payments.   Once the case has been reported, the BCRC will collect information from multiple sources to research the MSP situation, as appropriate (e.g., information is collected from claims processors, Medicare, Medicaid, and SCHIP Extension Act (MMSEA Section) 111 Mandatory Insurer Reporting submissions, and worker’s compensation entities).  If the BCRC determines that the other insurance is primary to Medicare, they will create an MSP occurrence and post it to the Medicare records. If the MSP occurrence is related to an NGHP, the BCRC uses that information as well as information from CMS’ systems to identify and recover Medicare payments that should have been paid by another entity as primary payer. After the MSP occurrence is posted, the BCRC will send the beneficiary a Rights and Responsibilities (RAR) letter. The RAR letter explains what information is needed from the beneficiary and what information can be expected from the BCRC. Please note: If Medicare is pursuing recovery directly from the insurer/workers’ compensation entity, the beneficiary and their attorney or other representative will receive recovery correspondence sent to the insurer/workers’ compensation entity.  The BCRC then begins identifying claims that Medicare has paid conditionally that are related to the case, based upon details about the type of incident, illness or injury alleged. Medicare’s recovery case runs from the “date of incident” through the date of settlement/judgment/award (where an “incident” involves exposure to or ingestion of a substance over time, the date of incident is the date of first exposure/ingestion). Within 65 days of the issuance of the RAR Letter, the BCRC will send the Conditional Payment Letter (CPL) and Payment Summary Form (PSF). The PSF lists all items or services that Medicare has paid conditionally which the BCRC has identified as being related to the pending case. The CPL explains how to dispute any unrelated claims and includes the BCRC’s best estimate, as of the date the letter is issued, of the amount Medicare should be reimbursed (i.e., the interim total conditional payment amount). The conditional payment amount is considered an interim amount because Medicare may make additional payments while the case is pending. If there is a significant delay between the initial notification to the BCRC and the settlement/judgment/award, the beneficiary, attorney or other representative may request an “interim conditional payment letter” which lists the claims paid to date that are related to the case.  The current conditional payment amount can be obtained from the BCRC or the Medicare Secondary Payer Recovery Portal (MSPRP). To obtain conditional payment information from the BCRC, call 1-855-798-2627. Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?    Contact us for more information! Stay tuned for Part V of our MSA Reporting Series – What Happens When A Claim Is Reported After A Case Is Settled? Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement,  review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!

The Medicare Secondary Payer (MSP) provisions make Medicare a secondary payer to certain non-group health plans (NGHPs), which include workers’ compensation entities, liability insurers (including self-insured entities), and no-fault insurers.  CMS has the right to recover Medicare payments made that should have been the responsibility of an NGHP or another payer.

MSP situations involving NGHPs are typically triggered by unexpected incidents, such as car accidents or work-related injuries involving Medicare beneficiaries, and result in medical expenses for which an NGHP has primary responsibility for payment, instead of Medicare. 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. These are known as “Conditional Payments.” 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.

Other common situations in a workers’ compensation claim that may result in conditional payments for a Medicare Beneficiary include (but are not limited to):

• Bills for services related to treatment for the industrial injuries are inadvertently sent to Medicare either by the treater or patient (Medicare beneficiary)
• Items and services are denied; the patient submits the bills to Medicare and the services or items are eventually accepted under the claim
• The patient goes to a provider for a service not related to the claim, but claim related issues are discussed or treated in the same visit and on the same record (more common with providers such as Kaiser)

The Benefits Coordination & Recovery Center (BCRC) is responsible for ensuring that Medicare gets repaid by the beneficiary for any conditional payments it makes related to a liability, no-fault, or workers’ compensation case for parts A and B claims.  When the BCRC learns of an NGHP case, they will gather information about any related conditional payments Medicare made and request repayment.

Please note that recovery for parts C (Medicare Advantage Plan) and D (Optional Prescription Drug Plan) claims are the responsibility of the issuing plan and separate inquires may be required.

It is important to understand any outstanding conditional payment amounts prior to settlement, so that the exposure for those payments can be considered by the carrier when setting reserves for settlement funding.  Otherwise, the Applicant/Beneficiary may receive an unexpected bill for any owed conditional payments post settlement.

To obtain a conditional payment information, interested parties may contact BCRC Customer Service Representatives Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays, at toll-free lines: 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for the hearing and speech impaired).

Note that Medicare does not release information from a beneficiary’s records without appropriate authorization. If the beneficiary has an attorney or other representative, he or she must send the BCRC documentation that authorizes them to release information.  The attorney or other representative will receive a copy of the RAR letter and other letters from the BCRC as long as he or she has submitted a Consent to Release form.

A Consent to Release (CTR) authorizes an individual or entity to receive certain information from the BCRC for a limited period of time. With that form on file, the attorney or other representative will also be sent a copy of the Conditional Payment Letter (CPL) and demand letter. If the attorney or other representative wants to enter into additional discussions with any of Medicare’s entities, a Proof of Representation document will also need to be submitted. A Proof of Representation (POR) authorizes an individual or entity (including an attorney) to act on your behalf.  It is in the best interest of both sides to have the most accurate information available regarding the amount owed to the BCRC prior to settlement.Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?    Contact us for more information!

Questions about MSAs,  future medical cost projections/life care plans or posturing your cases for future medical settlement? Click here for more information.

Stay tuned for Part IV of our MSA Reporting Series – What Happens When A Claim Is Reported to CMS?

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.  

Our step-by-step process to get MSS working for you couldn’t be EASIER:

• Use our client portal at medicalsettlementspecialists.com to 
  complete a case intake form and upload documents.
• On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement,  review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.)
• Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!

The Benefits Coordination & Recovery Center (BCRC) is responsible for ensuring that Medicare gets repaid by the beneficiary for any conditional payments. If an injured worker has Medicare and other insurance coverage, each type of coverage is called a “payer.”  When there’s more than one potential payer, there are coordination rules to decide who pays first.   Medicare may pay secondary to no-fault insurance, liability insurance or workers’ compensation. To ensure correct payment of Medicare claims, CMS advises Medicare Beneficiaries to always contact the BCRC first whenever they have a pending Liability, No-Fault, or Workers’ Compensation case.  According to CMS, this obligation is fulfilled by reporting the case in the Medicare Secondary Payor Recovery Portal (MSPRP) or by contacting the Benefits Coordination & Recovery Center (BCRC).  Often in workers’ compensation claims however, CMS is first notified that a Medicare Beneficiary has a workers’ compensation claim when the claim is reported via Section 111 reporting via the Responsible Reporting Entity (RRE) as noted in Part I of our series and/or when an MSA is submitted to CMS for review.   Once the case has been reported, the BCRC will collect information from multiple sources to research the MSP situation, as appropriate (e.g., information is collected from claims processors, Medicare, Medicaid, and SCHIP Extension Act (MMSEA Section) 111 Mandatory Insurer Reporting submissions, and worker’s compensation entities). Beneficiaries can access the MSPRP through the Medicare.Gov Web site using their established Login ID and Password for that site. The Web site can be accessed from the link: www.Medicare.gov.  Insurers and attorneys will access the MSPRP using the MSPRP Application link: https://www.cob.cms.hhs.gov/MSPRP/. Please note that registration must occur before access to the MSPRP is permitted.  Once notified, the BCRC will begin identifying claims that Medicare has paid conditionally that are related to the case, based upon details about the type of incident, illness or injury alleged. Medicare’s recovery case runs from the “date of incident” through the date of settlement/ judgment/ award (where an “incident” involves exposure to or ingestion of a substance over time, the date of incident is the date of first exposure/ingestion). Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?    Contact us for more information! Questions about MSAs,  future medical cost projections/life care plans or posturing your cases for future medical settlement? Click here for more information. Stay tuned for Part III of our MSA Reporting Series – Conditional Payments Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to  complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement,  review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!

CMS stands for the Centers for Medicare & Medicaid Services.  In relationship to a workers’ compensation claim, CMS is responsible for protecting the Medicare program’s fiscal integrity and ensuring that it pays only for those services that are its responsibility.  CMS captures Medicare Set-Aside (MSA) information via the Section 111 reporting process of the Medicare, Medicaid, and SCHIP Extension Act for workers’ compensation settlements.   It is currently the position of CMS that while it might be possible to tie a voluntary Workers’ Compensation Medicare Set-Aside (WCMSA) submission to a Total Payment Obligation to Claimant (TPOC) report based on the beneficiary information and Date of Incident (DOI), CMS cannot guarantee that the parties are using the voluntary WCMSA amounts, as parties may have decided to use an Evidence-Based MSA, another type of unsubmitted MSA, or otherwise settled future medical where a case does not meet review thresholds. Therefore, effective April 4, 2025, CMS started mandating Section 111 reporting of WCMSA data for all settlements (including those with zero dollar allocations) involving injured workers who are, or were Medicare beneficiaries. This includes any settlements below the CMS review threshold of $25,000.00.  In general, the Responsible Reporting Entities (RRE) who must report per Section 111 are self-insured employers, liability insurers, workers’ compensation insurers and third-party administrators. This reporting is mandatory, regardless of whether the WCMSA is approved by CMS or not.  Per CMS: Failure of an RRE to comply with its reporting obligations may result in CMS utilizing all available statutory and regulatory options to recover mistakenly made payments, including bringing an action against the RRE under the False Claims Act. Section 111 reporting is not a replacement for submission of settlement documents which is still required by CMS to finalize the WCMSA approval process.  CMS review remains voluntary and the review thresholds are unchanged. Despite the fact that not all cases involving future medical settlements are eligible for CMS review, CMS review and approval is the only process that offers both Medicare beneficiaries and defendants finality.  When CMS approves a proposed WCMSA amount, CMS will stand behind that amount.  Without CMS’s approval, Medicare may deny related medical claims, or pursue recovery for related medical claims that Medicare paid up to the full amount of the settlement, judgment, award, or other payment. Not all cases are “eligible” for an opportunity to be approved by CMS, yet all settlements consider Medicare’s interests.  Therefore, it is more important than ever to have an accurate understanding of future medical exposure in all cases involving future medical settlements. Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?    Contact us for more information! Schedule time to discuss how MSS can assist you identify and value your client’s future medical care needs! Click here for more information. Stay tuned for Part II of our MSA Reporting Series – Reporting a Medicare Beneficiary’s Workers’ Compensation Claim to CMS Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to  complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement,  review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!

Recently, Medical Settlement Specialists, along with carrier MSA venders and other entities dealing with MSA submissions, have noticed a significant increase in CMS development requests, particularly in the area of CMS requesting that the submitter essentially “prove” that all claim related records for the most recent 2 years of treatment, regardless of who paid for the treatment, were submitted in entirety to CMS along with the proposed MSA allocation.   The critical initial phase of the MSA review process is conducted for CMS by the Workers’ Compensation Review Contractor (WCRC). The WCRC is a specialized contractor hired by CMS to review and evaluate WCMSA proposals.   If the WCRC identifies missing or insufficient information during its review, it will issue a development request to the submitter. This request asks for additional documentation or clarification to complete the review.   The following is an excerpt from one such development request, and is similar or identical to development requests received in multiple jurisdictions by multiple MSA submitters across the county.  It appears that this language is “boilerplate” and sent regardless of the case specifics.    “Send updated medical records for all major surgeries/procedures and the most recent two years of treatment records related to the industrial injury from all treating physicians, even if the carrier has not paid for the treatment. Medical records for the most recent two years of treatment related to the industrial injuries/conditions are needed, which may not be within the last two calendar years.”   “If the industrial injury occurred less than two years ago, send all medical records from the date of injury through the date of submission. AME/IME/Med-legal reports are not a substitute for treating physician records. If the claimant has not been treated by a doctor for any reason within the last two calendar years, send a statement from the treating physician(s) indicating when the most recent two years of treatment related to the industrial injury occurred along with the medical records from those most recent two years of treatment.”   “A statement indicating the claimant has not been treated in the last two years is not a substitute for medical records for the most recent two years of treatment. Include all medical records related to the industrial injury for the most recent two years prior to the last treatment date.”   These development requests are being sent on cases where the submitter confirmed for CMS that all claim related treatment records with the most recent 2 years of treatment were in fact, submitted with the initial proposal.    The submitter will typically be told the information must be submitted within 10-20 days of the request or the case will be closed.  The good news is the case is easily reopened when the information is received.  However, the time and expense incurred in researching and responding to these requests can be significant.   In addition, these requests for ‘current’ medical records, pharmacy history, and/or an updated carrier payout becomes a vicious cycle in cases where the patient continues to treat, and can result in a repeated development requests. We’ve watched cases being closed and re-opened multiple times, causing the CMS review process to extend far beyond 6-8 weeks.  From the WCRC perspective, a closure due to missing information places the burden back on the submitter and the case is technically complete; the WCRC has done their job.   The result of this recent increase in development requests is that claims are taking longer to settle or not settling at all based on lack of CMS approval.  All parties become frustrated by the delays.   If settlement is pursued, parties may consider language making closure contingent on CMS acceptance, or the settlement may cover indemnity only, leaving medical open. Of course an alternative option is to move forward without CMS approval of an MSA, essentially using the MSA allocation as a “nonsubmit” MSA and this is certainly a trend we are seeing.   When relying on the carrier MSA proposal without CMS approval, it is important to have  an accurate understanding of future medical needs based on CMS submission guidelines.     In reality, many cases will not even meet CMS review thresholds, yet all settlements must consider Medicare’s interests.  Regardless of the reason for non-submission, it is important to have an accurate understanding of the future medical exposure in all cases involving future medical settlements. This allows you to optimize your position during settlement negotiations. Let MSS assist you in navigating MSA reviews and nonSubmit MSA situations!  Do you have additional questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?    Contact us for more information! Schedule time to discuss how MSS can assist you identify and value your client’s future medical care needs! Click here for more information. Stay tuned for Part I of our MSA reporting Series – What Are the New Medicare Reporting Rules!

Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to  complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement,  review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!

Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to  complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement,  review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!

CMS has an updated guideline regarding request for review after an MSA has been submitted.
When the following criteria are met, CMS will permit a one-time request for re-review :

• CMS has issued a conditional approval/approved amount.
• The case has not yet settled as of the date of the request for re-review.
• Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.
• Request must include submission of a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release information, and a summary of expected future care
• When a re-review request is reviewed and approved by CMS, the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased.

 
Additional criteria may apply depending on case circumstances.    

 Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?  Contact us for more information!

Schedule time to discuss how MSS can assist you identify and value your client’s future medical care needs!

Click here for more information.

For over 20 years Medical Settlement Specialists has been the Applicant Attorneys’ Go-To resource for all things future medical.  
 
As a company dedicated to serving our clients in a personalized manner with customized products, we recognize the need to keep our services cost-effective and our delivery efficient.  
 
We provide this level of service by focusing our craft on educating attorneys regarding future medical care requirements and associated carrier exposure value.
 
We remain cost-effective by relying on speaking/sponsorship opportunities and word-of-mouth referrals as part of our marketing. 
 
If you have found our services useful, would you kindly consider providing a testimonial and referring us to your co-workers and fellow attorneys?

We thank you for your business and look forward to working with you again soon!

Schedule time to discuss how MSS can assist you!

What do we deliver?

• Future Medical Exposure Analysis on cases of all sizes for use during case planning and settlement negotiations regardless of Medicare involvement
• Valuations supported by Medicare and/or state guidelines 
• Support during settlement proceedings/mediation 
• Bulk settlement capability (multiple cases with same carrier/defense – “Settlement Days”)
• Alliances with other consultants to offer a wide range of settlement options for structuring and custodial account management
• Peace of mind – our services provide information that contributes to your ability to know the medical facts of your case, educate your clients accordingly, and document the responsibility and care exercised in assessing the medical value of the claim

Schedule time to discuss how MSS can assist you!