Under Medicare Secondary Payer law (42 U.S.C. § 1395y(b)), Medicare does not pay for items or services to the extent that payment has been, or may reasonably be expected to be, made through a no-fault or liability insurer or through Workers' Compensation (WC). Medicare may make a conditional payment when there is evidence that the primary plan does not pay promptly conditioned upon reimbursement when the primary plan does pay. The Benefits Coordination & Recovery Center (BCRC) is the organization responsible for recovering conditional payments when there is a settlement, judgment, award, or other payment made. When the BCRC has information concerning a potential recovery situation, it will identify the affected claims and begin recovery activities. Beneficiaries and their attorney(s) should recognize the obligation to reimburse Medicare during any settlement negotiations.
Specialty Allocations performs Medicare Conditional Payment Verification to determine if the claimant owes any conditional payments to Medicare. Once we receive proper consent forms signed by the claimant, we will identify existing conditional payments through BCRC’s estimate of the conditional payments. Our staff is both experienced and efficient when it comes to the conditional payment process. We provide frequent updates and copies of all mailed correspondence to the referral source.
Specialty Allocations performs Medicare Conditional Payment Negotiation to determine if any of the conditional payments are unrelated to the pending claim. Our medical team will review the medical records in order to accurately identify the ICD-9 codes so that they can be reported to the Coordination of Benefits Contractor (COBC). In order to receive the conditional payment summary, the injuries need to be reported to COBC. Once we receive the Conditional Payment Letter we will review for improper charges, and if applicable, we will contact the BCRC in order to have the unrelated charges removed prior to settlement.
Upon the receipt of the claimant’s signed releases, Specialty Allocations will submit a lien search request to the BCRC. After the request is received, a Rights and Responsibilities Letter is issued to the Medicare beneficiary and any authorized individuals listed on the Proof of Representation authorization. The Rights and Responsibilities Letter provides general information on Medicare’s rights, in addition to, the beneficiary and representative responsibilities. Within 65 days of the issuance of the Rights and Responsibilities Letter, a Conditional Payment Letter is issued. A Conditional Payment Letter provides information on the items or services that Medicare conditionally paid and what was identified as being related to the pending claim.
In some cases, items outlined in the Conditional Payment Letter are unrelated to the claim. When this occurs, Specialty Allocations’ registered nurses can review each item line by line and determine what is related to the claim and what is not. Once these items are identified, a dispute can be submitted to the BCRC. We have many success stories of significantly reducing the conditional payment amounts. We strive to the keep the Medicare conditional payment repayment obligation as low as possible, in order for the claimant to receive the most from their settlement.
Once the settlement has been finalized, the Final Settlement Detail Documents needs to be submitted to BCRC. The Final Settlement Detail Document includes the total settlement amount, itemization of costs including attorneys fees and costs, and date of settlement. BCRC will generate a Final Demand Letter when they receive the settlement information. Payment is due within 60 days of the date of the demand letter. If payment is not received within 60 days, interest will be charged from the date of the demand letter. Once payment is received, BCRC will issue a letter confirming the receipt of payment and acknowledging that the case has been closed.
555 Winderley Place, Suite 300
Maitland, FL 32751