October 2010

MSPRC- Conditional Payment Process

Did you know that as a Medicare Beneficiary, the Claimant receives a "Rights & Responsibilities" letter from the Medicare Secondary Payer Recovery Contractor (MSPRC)? Receiving this letter and their brochure means that the Liability, (Including Self Insurance), No-Fault, and or Workers Compensation case has already been established through the Coordination of Benefits Contractor and with the MSPRC. From then on, the MSPRC compiles all medical claims that Medicare paid that are related to the case at hand. This process takes approximately 8 weeks. The MSPRC is not able to provide conditional payment amounts until all claims are retrieved from Medicare's system. Once all claims have been retrieved from Medicare systems and relatedness to the case determined, then the MSPRC, on average, will issue the "Conditional Payment Letter" (CPL) within 65 days from the date of the "Rights & Responsibilities" Letter. For more information, please see the MSPRC brochure at:

CMS Review Thresholds

A Medicare Set Aside Proposal is submitted to CMS (Centers for Medicare and Medicaid Services) for review in the following situations: The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; OR The claimant has a "reasonable expectation" of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.

With the Medicare Secondary Payer Mandatory Reporting legislation now in its final stages of production claim Input Files (72 days to go) for all liability insurance (including self insurance), no-fault insurance, and workers' compensation RRE's based upon a predetermined schedule with the COBC. Beginning 01/01/2011, these entities will be mandated to submit their Section 111 production Claim Input Files or face possible penalties and or fines! Most data reporting agents are charging over $15,000 for set-up negotiations with CMS for RRE reporting. As you know, we have a "Lowest Price Guarantee" and continue to offer this service at a "reduced cost" as part of the MSA Data Reporting and Approval Package. If you still have not yet selected a data reporting vendor and are not yet ready with your reporting, then please give us a call today for more information in this regard. We can help you with total CMS Compliance!