With all of the recent changes, updates, and alerts coming from CMS, it is important to remember that various aspects of MSP compliance directly impact one another. Namely, Section 111 reporting and conditional payment appeals. This past week, AKCS was tasked with resolving a lien in excess of $350,000 and a detailed analysis of the Section 111 reporting proved to be key in reducing this amount to $0.

Background of the Case

The initial demand amount was a staggering $350,743.86 for a workers’ compensation claim accepted for the low back, strain only. Upon a full review of the claim file as well as the past Section 111 reporting, several key points were noted:

• Claim Last Reported: 2/3/2020
• ORM Termination Date: N/A
  • However, it was identified that the Claimant was released from care with no future medical indicated as of May 26, 2015, prior to the claimant’s Medicare entitlement date
• Payment History: Only $150.00 was paid in medical expenses

Confirming the ORM Termination Date

The first step in the appeal process was to confirm the accuracy of the ORM termination date. After reviewing past medical and conferencing with the carrier, it was confirmed that the ORM termination date of 5/26/2015 was accurate. This date was crucial as it was prior to the claimant’s Medicare entitlement date.

Crafting the Appeal

With the confirmed ORM termination date, an appeal was drafted to advise the Commercial Repayment Center (CRC) of the following points:

1. ORM Termination Date: The ORM was terminated on 5/26/2015.
2. MSP Record Deletion: Confirmation from a BCRC (Benefits Coordination & Recovery Center) representative that the MSP record was deleted.
3. Primary Diagnosis Codes: Highlighting that none of the primary diagnosis codes on the demand were related to the low back strain.

Outcome of the Appeal

The appeal was successful, and the demand was reduced to $0. This case study underscores the importance of thorough documentation, accurate reporting, and clear communication with the relevant authorities. By researching and verifying the ORM termination date and ensuring that the MSP record was deleted, the appeal was able to highlight discrepancies and ultimately lead to a favorable outcome.

Key Takeaways

• Accurate Documentation: Always ensure that all dates and details are accurately documented and verified.
• Clear Communication: Maintain clear and consistent communication with relevant authorities and contractors.
• Thorough Review: Carefully review all aspects of the claim, including payment history and diagnosis codes, to identify any discrepancies.

Navigating the complexities of MSP appeals can be daunting, but with careful attention to detail and a methodical approach, it is possible to achieve successful outcomes. This case serves as a testament to the importance of diligence and precision in the appeals process.

For questions about any aspect of the conditional payment resolution process, as well as general inquiries about Section 111 Reporting compliance please contact us at info@allankoba.com.