Conditional Payment Resolution

Medicare has the right to recover payments it has made on claims which should have been covered or could have been reasonably expected to have been covered by another Payer Source. Such reimbursements to Medicare are known as Conditional Payments. Recent changes to the Medicare mandate include a recovery process for obtaining reimbursement for conditional payments.

Parties must act promptly and thoroughly to investigate whether Medicare has a claim for Conditional Payments, negotiate with Medicare on the basis of relationship of charges to the covered injuries, and arrange for prompt reimbursement to Medicare of undisputed charges.

Failure to address the issue of conditional payment reimbursement can subject the primary payer to double damages, result in a loss of benefits for the injured individual, and subject other parties (including attorneys) to a potential action from CMS.

ANS Rehab Consulting works to ensure that Conditional Payments do not become an obstacle to settlement by getting involved early in the process. Reducing undue financial burden on any of the parties, ANS serves as an intermediary with CMS to respond to and negotiate payments due.

In an effort to expedite payment, the Centers for Medicare & Medicaid Services (CMS) has hired an entity known as the Medicare Secondary Payer Recovery Contractor (MSPRC). The MSPRC issues demands for reimbursement of Conditional Payments. Once these demands have been served, Parties must act promptly to respond and to resolve the demand in order to avoid penalties and interest.

ANS’ primary roles in responding on behalf of clients receiving Conditional Payment demands are to determine whether the payments were for services which were in fact covered under the policy, respond to MSPRC on behalf of the client, and negotiate and finalize the amount due.

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