Key Takeaways from Sanderson Firm’s Recent Medicare Advantage Plan Conditional Payment Webinar

Just a few weeks ago, Sanderson Firm hosted a national webinar on the latest in Medicare Advantage Plan (MAP) conditional payment recovery trends, featuring special guest speaker Brian Bargender, who is employed as a Senior Payment Integrity Professional at one of the largest MAPs in the country. Brian is a frequently requested expert on MAP conditional payment recovery efforts and Medicare Secondary Payer (MSP) compliance and provided some invaluable expertise during the webinar. If you missed the webinar and would like to view the webinar recording to glean mine and Brian’s expert insights on the webinar, you can find it on YouTube here.

Key Webinar Takeaways:

Ø Settlement Agreement Language Insulation for Carriers - It is a misperception that settlement agreements which “punt” the traditional/MAP conditional payment reimbursement obligations to the Medicare beneficiary and/or their attorney insulates payers from liability. MAPs all handle their conditional payment recoveries differently, but generally, if a MAP does not receive reimbursement or a response from a beneficiary for a conditional payment demand, the MAP will seek recovery from the primary payer.

Ø MAP Plans cannot refer debts to the Department of Treasury - It is important to note that MAP plans cannot send debts to the Department of Treasury like the Federal Government/Traditional Medicare can; thus, MAPs are often in the predicament that they must pursue recovery from the payer or file a double damages private cause of action against the payer. The Medicare program/Centers for Medicare & Medicaid Services (CMS) does put pressure upon MAPs to pursue conditional payment recoveries.

Ø MAP Plans Recovery Processes – MAP Plans are by and large expected to follow the same general recovery “processes” as traditional Medicare. In addition to recovery rights/parameters being the same, MAP carriers are expected to accept dispute/appeal arguments that traditional Medicare allows. MAPs do not receive clear guidance regarding from CMS exchange of information with primary payers and may require different forms of authorization than CMS requires for traditional Medicare.

Ø Placing MAPs on notice of your claim – It was suggested that placing MAPs on notice of your claim as soon as a plan is identified is key to preventing conditional payments down the road. The goal of the MAP is to understand a claim exists and prevent making payments in the first place. This may aid is more expedient settlements.

Ø MAP Enrollment on the rise- Currently 49% of Medicare beneficiaries are enrolled in a MAP plan and this number is expected to continue to rise. Establishing best practices surrounding MAP enrollment identification and lien investigation and resolution is and will continue to be critical for your claim’s organization. Depending on the age of your claim and date of Medicare entitlement, you may find there are multiple MAP plans in play when attempting to settle your claim.

There were a lot of great questions surrounding this critical topic and unfortunately, due to the volume and complexity of the content, there was not enough time to answer all our participants’ questions live. Below are some questions that were asked and Sanderson Firms commentary.

Questions Asked During the Webinar and Sanderson Firm’s Answers:

1.    “If there is a settlement with multiple payers, who becomes ultimately responsible for conditional payments?”

Ultimately, all payers in a settlement with a Medicare beneficiary which includes the alleged claim and/or release for medical treatment against that payer are responsible for reimbursing Medicare/MAPs for conditional payments. If there is joint and several liability, then all contributing defendants must report the total global settlement amount to CMS via Section 111 reporting. Ultimately, in scenarios with multiple payers, there should be a coordinated/planned effort in how the defendant parties will ensure that any traditional and/or MAP conditional payments are reimbursed.

2.   “Can you address how we can get MAP plan information? There’s so much fraud out there, claimants are reluctant to share their Medicare card info and then there’s no way to know what plan they have and who to contact!”

This is a great question and the reason behind why the MSP industry lobbied for and had the Provide Accurate Information Directly (PAID) Act passed as law in December of 2020. Effective December 11, 2021, primary workers’ compensation, general liability, and no-fault insurance plans/payers now receive Medicare enrollment data across Medicare Parts A, B, C, and D for the last 3 years, up to 12 instances. With the PAID Act data, MAP contact information and enrollment dates are provided so that if the payer wants to proactively resolve any MAP conditional payments, the payer and/or their MSP firm may reach out and resolve any outstanding MAP conditional payment liabilities. Additionally, Sanderson Firm does provide a MAP/Part D Enrollment Verification service.

3.    “Just to confirm, PAID Act data only shows enrollment in a plan vs. payments that plan may have made, correct?”

That’s correct. The MAP plan must be contacted to obtain the current conditional payment amount owed.

4.    “How would a payer request a lien, rather than waiting for Humana or other MAP plan to send one?”

The MAP plan’s subrogation department or their third-party subrogation partner must be contacted to obtain the conditional payment amount. Confirming the correct party to send lien requests to can be a lengthy process and some MAP plans are delayed as long as six (6) months in responding to these requests; thus, parties looking to settle a claim with a Medicare beneficiary should start the MAP conditional payment process early and work with an expert to obtain optimal outcomes in reducing the amount owed.

5.    “The name and address that comes through the PAID act to RRE's is not current and Medicare has told us the MAP plans need to update their address with them period when will the MAP plans update their correct address with Medicare?”

Sanderson Firm has observed some inaccuracies/inconsistencies in PAID Act data being transmitted from CMS. As a failsafe, we recommend also having the Medicare beneficiary provide an attestation of all MAP plans they have been enrolled in since the inception of the claim so that all MAP conditional payments can be resolved. Having both the PAID Act data as well as the Medicare beneficiary provide all their MAP plan enrollments in writing helps payers be able to have greater insight into ALL MAP plans that may have a claim for reimbursement for conditional payments. Note that while our topic largely centers around the PAID Act, there may be MAP plans older than 3 years that have coverage overlap with your claim and lien investigation and resolution is appropriate with these plans as well.

Sanderson Firm provides comprehensive services surrounding identification of Medicare beneficiaries and their MAP enrollment status as well as conditional payment identification, dispute and resolution services including Traditional Medicare, Part C Medicare Advantage Plans (MAPs), and Part D Prescription Drug Plans. Our average reduction of conditional payment demands is 80%. Please contact me if you have any questions on MAP conditional payment recovery services, please contact me at heather@sandersoncomp.com.