CMS Conditional Payment Recovery Changes Ahead

CMS Conditional Payment Recovery Changes Ahead

CMS has announced they will be transitioning a portion of the NGHP conditional payment recovery workload from the Benefits Coordination & Recovery Center (BCRC) to what is called the Commercial Repayment Center (CRC). Effective October 2015, the CRC will assume responsibility for the recovery of conditional payments where the Centers for Medicare & Medicaid Services (CMS) is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity (collectively, Applicable Plans) as the identified debtor.

The CRC will be issuing Conditional Payment Notices(CPN’s) when the Applicable Plan indicates through Section 111 MIR that it has accepted Ongoing Responsibility for Medicals. The CPN will include conditional payment information on a Statement of Reimbursement (SOR) with items or services paid by Medicare it seeks to recover, will  explain how to dispute any item or service included in the SOR, and will advise insurers and entities what further actions need to be taken. If the CPN is not disputed within 30 days, a Demand Letter will follow requiring payment by the Applicable Plan. Clearly it is extremely important to take a pro-active approach in dealing with and resolving conditional payments.

So in short, we now have a new recovery contractor who is 1) paid based on a contingency fee(which may well signal much more aggressive recovery efforts), 2) who is in charge of pursuing recovery directly from Applicable Plans and 3) may now be pursuing recovery even before a settlement, judgement or award. This will undoubtedly result in a significant uptick in the number of conditional payment notices received starting in October, 2015.

Axiom National is here to assist you in effectively disputing and resolving Conditional Payment Notices received by the CRC. Medicare compliance and settlement planning is all we do, and we would welcome the opportunity to earn your trust and your business.

For questions or additional information please contact Geoffrey Hudson at 1-888-826-6496, or

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