Medicare Conditional Payment Disputes and Appeals: Hire a Lawyer!
Rafael Gonzalez, Esq.
speaker, blogger, podcaster, adjunct, attorney providing medicare/medicaid counsel nationwide on secondary payer issues in liability, no-fault, and work comp claims and litigated cases
When it comes to Medicare Conditional Payment Disputes and Appeals, Hire an Experienced and Knowledgeable Medicare Secondary Payer Lawyer
Have any of these happened to you or to your organization?
At Cattie & Gonzalez, we are still seeing a volume of cases with similar facts. Clients bringing to us these unfortunate circumstances arising for a number of reasons. Could be outdated MSP protocols. Could be erroneous assumptions. Could be as a simple as a reliance on a team member who is ill equipped to handle the growing complexities of MSP compliance.
Take, for example, a recent case in which the RRE, a self insured employer, had its national third-party administrator register as its reporting and recovery agent within CMS’ mandatory insurer reporting system. However, despite this, the CRC failed to copy the RRE and its recovery agent and sent correspondence to the incorrect entity and to the wrong address repeatedly.?
In March 2020, the CRC sent a Conditional Payment Notice (CPN) to the incorrect RRE at the wrong address. In May 2020, the CRC sent a demand letter to the same incorrect RRE and address. As a result of the CRC sending these letters to the wrong entity and wrong address, the RRE and TPA were unaware of any outstanding conditional payments owed to CMS/CRC, until the matter was referred to US Treasury for collection in November 2020. When the RRE asked its TPA and recovery agent for options and possible solutions, they were told there weren’t any. They were instructed to pay the debt and move on.
Does this sound familiar? Have you or your organization been provided the same advice by a non-lawyer MSP vendor? Have you made that payment and then wondered if you made the right decision? Have you inquired about appealing after the fact and getting your money back? If you have been told there are no options, no alternatives, no path, no appeals rights, then read on. Bottom line is there are viable alternatives, so don’t give up! There are options. There are remedies available to you and your organization. Read here as our law firm helped another client ultimately erase a conditional payment debt in excess of $50,000 improperly referred to the US Treasury for collection.
Facts.
On February 14, 2017, the claimant in this case suffered an alleged injury to her left knee while walking down a flight of stairs at work. The only injury claimed as part of this claim was the left knee. The only ICD code reported to Medicare through mandatory insurer reporting for ORM purposes was M25861.?
The medical records from February 14, 2017 forward clearly and unequivocally indicated the knee condition was NOT work related. Based on this medical evidence and its own investigation, the employer, through its third party administrator, denied the claim on June 3, 2017. ORM was terminated as of June 3, 2017.?
On behalf of Medicare, in March 2020, the CRC issued a conditional payment notice for conditional payments made in the amount of $54,003.62 for charges from July 23, 2019, through December 18, 2019. In May 2020, the CRC sent a final demand. Both of these were sent to the wrong RRE and wrong address. In addition, the records and payments described in these notices indicated treatment for M48061-spinal stenosis, M4316-spondylolisthesis of the lumbar region, M51116-intervertebral disc disorder, G4733-obstructive sleep apnea, and G544-lumbosacral root disorder, all conditions personal in nature to the claimant that had nothing to do with or in any way related to the February 14, 2017, work related knee injury that was denied on June 3, 2017.?
Since no response was provided or received (given the fact that neither the RRE or its administrator/recovery agent were aware of the debt), the matter became past due in June 2020. Consequently, the CRC sent a notice of intent to refer the debt to the US Treasury in August 2020 again to the same incorrect entity and address. Again, since no response was provided or received, the file was referred to the US Treasury in November 2020.
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Once at Treasury, one of the Treasury’s designated debt collection centers sent a notice of collection to the correct RRE at the correct address. This was the first time the RRE learned of this outstanding debt. As a result, the RRE immediately made contact with the Treasury collector, informed them they had never received prior notice of this debt, and further indicated that none of the payments requested were related to the denied left knee work comp claim. After several conversations with the Treasury designated debt collection agency in April, May, and June 2021, the RRE was informed it should file an appeal with the CRC.
After having several meetings with their national third party administrator, which also served as their reporting and recovery agent, the RRE was informed there was nothing it could do. Their recommendation was to pay the $52,734 original amount and the $5,498 interest accrued, thereby totaling $58,233 debt to the US Treasury even though none of the payments were related to the 2/14/17 date of accident.
Desperate, confused, frustrated, and disappointed, the RRE sought legal counsel about this situation. The RRE had worked with our firm previously and therefore already knew they wanted to speak with an expert Medicare secondary payer law firm regarding its options, available legal arguments, and further steps. Our firm entered the picture in July 2021, 17 months after the CRC’s conditional payment notice, 15 months after its final demand, and 9 months after the matter had been referred to US Treasury for collection.
Argument.
Pursuant to the Medicare Secondary Payer Act at 42 U.S.C. Section 1395y(b)(2) and 42 C.F.R. Section 411, conditional payments are reimbursable to Medicare only if such payments made by Medicare are the responsibility of the primary payer. Here, based on the strong, uncontroverted, and undisputed evidence, it was clear to us the RRE was not responsible for any of the payments made by Medicare, and for which it sought reimbursement, as the claim was denied on 6/3/2017. The charges presented were personal in nature to the claimant and had nothing to do or were in any way related to the February 14, 2017, work related knee injury that was denied on June 3, 2017.?
In addition to the CRC’s failure to copy the employer’s reporting and recovery agent (also the employer’s third-party claim administrator), the CRC incorrectly issued all letters, requests, and demands for reimbursement of conditional payments made for charges from July 23, 2019, through December 18, 2019, to the wrong RRE at the wrong address. As a result, our law firm recommended the RRE appeal the matter, requesting the CRC call back from the US Treasury the outstanding debt and remand it to the CRC for handling and dismissal.?
After receiving permission and authority from our client, the RRE, in August 2021, we filed a Request for Redetermination with the CRC and US Treasury, arguing that since the RRE had no knowledge of the final demand and referral of this matter to Treasury, as they were sent to the wrong employer at the wrong address, and all of the charges on the final demand were unrelated to the workers compensation knee injury, Medicare should pull the case back from the U.S. Treasury, remove all conditional payments from the final demand and close the case file.?
In September 2021, the CRC informed us that our request was deemed favorable, as the arguments made and documentation submitted provided sufficient cause to reverse their prior dismissal. The CRC agreed with our argument that none of the payments made by Medicare between July 23, 2019 and December 18, 2019 were in any way related to the February 14, 2017 work comp knee injury claim that was denied on June 3, 2017. As a result, the CRC removed all charges and closed the file in September 2021.
Conclusion.
This is not an unusual story; unfortunately, we see a lot of cases like this on a monthly basis. Situations where the Medicare beneficiary, his/her counsel, or the corporate defendant, and its insurer/administrator, were told by their MSP vendor there was nothing that could be done, there were no other options, there was no legal remedy or arguments to be made. It is not unusual for us to see cases where months, if not years later, Medicare will request reimbursement of large sums of monies, with US Treasury engaged and involved in trying to collect such an outstanding debt. These may be situations where your traditional MSP vendor, your reporting and recovery agent may have little experience in, may not be fully aware of, or may not be able to assist you with the legal representation needed to win the day. As we have been recommending for years, in addition to your traditional MSP vendor, you should also add at least a law firm to your panel to help and assist with legal issues pertaining to resolution of conditional payments. We would be honored for your considering adding us to your panel and allowing us to serve you in this capacity.
About Rafael Gonzalez, Esq.
Rafael is a partner in Cattie & Gonzalez, PLLC, a national law firm focusing its practice on federal Medicare/Medicaid secondary payer compliance and legal issues. In addition to assisting clients with Medicare mandatory reporting, conditional payments, and set asides issues, he helps clients with Medicaid third party liability liens and Medicaid special needs trusts issues. He has over 35 years experience in the liability, no-fault, and work comp insurance industry. You can connect with him on LinkedIn, Twitter, Facebook, and YouTube, or reach him at?[email protected], 844.546.3500, or?www.cattielaw.com.