Once an insurer reports acceptance of Ongoing Responsibility for Medicals (ORM), the Coordination Of Benefits Contractor (COBC) posts the associated injury codes on the Common Working File (CWF). Attempts by providers to bill Medicare for related treatment are denied. If all works well, the insurer will not see a reimbursement demand from the MSPRC; however, mistakes happen. If Medicare “mistakenly” pays a medical claim when another plan is primary (e.g., yours), the MSPRC will send a demand to the insurer. Medicare regulations also allow for Medicare to pay conditionally when the insurer denies that claim or when the beneficiary is incapacitated. In practice, there is no easy way for a provider to code a medical claim so they may be paid conditionally.
HHS Regulations for Group Health Plans
The regulations surrounding the ORM recovery of payments and the appeal process is well defined for Group Health Plans (GHP), but non-existent for Non-Group Health Plans. The GHP obligation to reimburse Medicare for mistaken and conditional payments can be found at 42 CFR § 411.10(b)(4) and (c)(1). The “defense” from such a reimbursement demand can be found at 42 CFR § 412 which states that the GHP can submit a copy of the policy that specifies services covered, conditions of coverage, benefit levels and limitations with respect to persons entitle to Medicare or with an explanation of the plan’s allegation that it does not owe CMS any amount. The GHP plan may appeal an MSPRC decision to a hearing officer (see 42 CFR § 411.115) and appeal the hearing officer’s decision to the Administrator under 42 CFR § 411.124. The decision of the Administrator is final, with no stated appeal to Federal Court. The penalty for a GHP plan for not reimbursing Medicare is “referral” to the Internal Revenue Service and the IRS is authorized by 42 CFR § 411.130(b) [to] ... impose[s] a tax on employers .. The tax is equal to 25 percent of the employer’s ... expenses.
Workers Compensation and No Fault Reimbursement
Medicare Advocacy Recovery Coalition (MARC) correctly asserts that there is no formal appeals process for Non-Group Health Plans and in particular situations in which a Workers’ Compensation and No-Fault plan has accepted ORM. In practice, the MSPRC will remove unrelated (disputed) medical claims much as they will do in liability. They may consider appeals based on lack of coverage as they do with Group Health Plans. The beneficiary has extensive administrative remedies and the insurer would do well to enlist their assistance, if other avenues of redress are foreclosed. There is no “referral” to Treasury or the IRS for non-payment. Medicare relies on their independent right to sue for double damages as the whip to ensure reimbursement.
