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Monday, December 21, 2015

CMS Implements SMART Act Functionality for Repayment

The Workers' Compensation community of stakeholders lobbied strenuously through 2012 for revision of the conditional payment process utilized by the Centers for Medicare and Medicaid (CMS). The SMART Act of 2012 codifies the process to comply with the Medicare Secondary Payer Act. CMS has now implemented an on-line process to facilitate reimbursement:

Modification of the Medicare Secondary Payer Recovery Portal (MSPRP) for Inclusion of Final Conditional Payment (CP) Process Functionality

As part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP has been modified to include Final CP process functionality.  This new functionality provides authorized MSPRP users with the option to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement, ensure that relatedness disputes are addressed within 11 business days of receipt of dispute documentation, request a Final Conditional Payment Amount, and obtain a time and date stamped final conditional payment summary document before reaching settlement.  Once the Final Conditional Payment has been calculated, this amount will not change as long as:
  1. The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
  2. Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.
A request for a Final Conditional Payment Amount can only be done once per case.  If the case is not settled with 3 days and/or the settlement information is not submitted through the MSPRP within 30 calendar days, the Final CP process will be voided.  At that time new claims may be added to the case and the CP amount will be modified accordingly.  Also, any subsequent disputes will not be held to the 11 day resolution timeframes.
  • Important Note:  An insurer and their authorized representatives can initiate the Final CP process on their insurer-debtor case as long as a settlement is pending on the case and no outstanding Ongoing Responsibility for Medicals (ORM) exists.  Once the Final CP process has been started on an insurer-debtor case, the following events will occur:
    The insurer-debtor case will be closed and the debt will be transferred to a new case where the beneficiary is the identified debtor.
    • The insurer and their authorized representatives will not be able to work the new beneficiary-debtor case or receive copies of any recovery-related correspondence related to the new beneficiary-debtor case until they obtain and submit an authorization signed by the beneficiary.
Jon L. Gelman of Wayne NJ is the author of NJ Workers’ Compensation Law (West-Thompson-Reuters) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson-Reuters). For over 4 decades the Law Offices of Jon L Gelman  1.973.696.7900  have been representing injured workers and their families who have suffered occupational accidents and illnesses.