By Marty Cassavoy, VP of MSP Compliance, ExamWorks Clinical Solutions
Not too long ago, Medicare conditional payments were something that workers’ compensation practitioners only dealt with at the time of settlement. That all changed in October 2015 when Medicare flipped the script and introduced the concept of “rolling recovery.” What is rolling recovery? And, most importantly, how can workers’ compensation claims payers address this critical compliance issue?
Conditional Payments in the Workers’ Compensation Context
Workers’ compensation claims payers have been primary to Medicare for over fifty years. If a Medicare beneficiary has a workers’ compensation claim, the employer or insurer pays for claim-related medical treatment. If bill slips past the goalie and Medicare makes payment for injury-related care, then Medicare’s payment is “conditioned upon later reimbursement” to Medicare. These payments by Medicare are known as “conditional payments.” Medicare has a right to directly recover the full amount of any conditional payment from both responsible primary payers as the recipient of primary payments – including the claimant, claimant’s attorney, and medical providers.
The Rolling Recovery Era
Historically, Medicare only exercised its recovery rights at the time of workers’ compensation settlement. In many states where a full and final workers’ compensation settlement is rare or non-existent – for example Texas, Massachusetts, and New Hampshire among several others – this meant that Medicare would never have an avenue of recovery and that conditional payments could conceivably go uncollected. That all changed almost four years ago when Medicare introduced “rolling recovery.”
Since 2010 federal law has required workers’ compensation claims payers report whenever it is presently responsible to pay for a Medicare beneficiary’s workers’ compensation medical benefit. This mandatory reporting provides a plethora of claim-related data. In October 2015 Medicare, sitting on a mountain of this claims data involving Medicare beneficiaries, chose to put that data to work in the recovery process. Medicare engaged a new contractor – the Commercial Repayment Center (CRC)– to recover against the claims payers who are presently responsible for a beneficiary’s workers’ compensation medical.
The CRC utilizes mandatory reporting data to identify “leads” on recovery claims. From there, the CRC notifies the primary payer and issues a demand. Medicare now recovers prior to settlement and on an unlimited and ongoing basis. As soon as a demand is resolved, the CRC is free to reissue another demand identifying even more treatment that Medicare paid for conditionally. This is why we call it “rolling recovery.”
The business problem is not only the multiplicity of demands, but their very content. Rolling recovery initiates huge swaths of claims that had never before been considered susceptible to a Medicare demand. Rolling recovery demand target any claim reported to Medicare where a workers’ compensation claims payer has “presently assumed” responsibility for medical care. Claims that will never settle; medical-only claims that exceeded $750 in medical payments; and even administratively closed claims are all susceptible to rolling recovery.
Rolling recovery has – at times – resulted in a tsunami of conditional payment demands. While at present we have seen a lull in the volume of demands that are being issued, it’s important to plan for the next wave. Here are three ways that claims payers can mitigate rolling recovery risk:
- 1. Timely and accurately update Section 111 data. Rolling recovery relies entirely upon the data transmitted via mandatory insurer reporting. Inaccurate or late updates can lead to unwanted (and unneeded) demands.
- 2. Centralize and standardize responses. Tremendous risks for over- and under-compliance exists in a decentralized response model. Rolling recovery impacts all aspects of a workers’ comp claims operation and the most successful and time-tested model involves a dedicated, centralized response.
- 3. Stay aggressive and proactive. The vast majority of conditional payment demands are either unrelated to the workers’ compensation claim and are clearly not the responsibility of the primary payer. Attack every notice and demand quickly and aggressively.
Conditional payments have a way of rearing their ugly head at the least opportune time. While we are currently at an ebb in the tide, the next wave could hit at any time and claims payers need to be prepared to address these risks with a centralized and coordinated process. ExamWorks Clinical Solutions has developed customized solutions to address and mitigate conditional payment risks. Our team of experienced attorneys, clinicians, and claims analysts are able to quickly and successfully reduce and often eliminate conditional payment claims.
About Marty Cassavoy
Marty Cassavoy is the Vice President of MSP Compliance for ExamWorks Clinical Solutions. Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer (MSP) compliance and across all insurance types.
Marty has been on the frontlines of just about every important moment in MSP compliance since the middle of the last decade. He is a trusted expert on both the technical and policy aspects of Section 111 reporting; sought-after advisor on investigating, addressing and responding to conditional payment matters; and an experienced innovator who has lent his expertise to develop program-level solutions of many of the industry’s most pressing problems. Marty is a frequent speaker, commentator and writer on all aspects of MSP compliance, where he is often unafraid to challenge the conventional approach to Medicare problems. Marty is a member of the ExamWorks Clinical Solutions Leadership Team, providing strategic guidance for the organization’s MSP compliance products and services. In his day-to-day role, Marty leads the Compliance Team where he and his talented team collaborate to solve problems, react to industry changes and build innovative MSP compliance solutions.
Marty is based in the Boston area and can be contacted by phone at 781-517-8085 or email at firstname.lastname@example.org.
About ExamWorks Clinical Solutions
ExamWorks Clinical Solutions is a leading authority on Conditional Payment Resolution, Medicare Set-Asides (MSAs), Evidence-based MSAs, and MMSEA Section 111 reporting. Our Nurses, Certified Life Care Planners, Doctors of Pharmacy, and Attorneys deliver accurate and defensible Legal Nurse Reviews, Life Care Plans, Field Case Management, and settlement strategies on a proprietary platform enabling efficient communications and service delivery.