Insurer/Third Party Administrator Services

Group Health Plans (GHPs), Third Party Administrators (TPAs), liability and no-fault insurers, and workers’ compensation entities all have an obligation to ensure benefit payments are made in the proper order and to repay Medicare if mistaken primary payments are made or if there is a settlement, judgment, award or other payment made for services paid conditionally by Medicare. The Medicare program uses Coordination of Benefits (COB) processes to identify payers primary to Medicare and Medicare Secondary Payer (MSP) recovery processes to recover mistaken primary payments and conditional payments.

Coordination of Benefits

The Benefits Coordination & Recovery Center (BCRC) consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The BCRC takes actions to identify the health benefits available to a Medicare beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims or claims specific inquiries. The Medicare Administrative Contractors (MACs), intermediaries and carriers are responsible for processing claims submitted for primary or secondary payment.

When to Contact the BCRC:

The BCRC should be contacted to:

• Report employment changes, or any other insurance coverage information
• Report a liability, no-fault, or workers’ compensation case
• Ask general MSP questions
• Ask questions regarding MSP development letters and questionnaires

For additional information regarding Coordination of Benefits, click the Coordination of Benefits link.

Medicare Secondary Payer (MSP) Recovery

MSP is the term used by Medicare when Medicare is not responsible for paying first. The MSP statute and regulations require Medicare to recover primary payments it mistakenly made for which a GHP is the proper primary payer.

If Medicare paid primary when the GHP had primary payment responsibility, the Commercial Repayment Center (CRC) will seek repayment by issuing a recovery demand letter to the employer with a copy to the insurer or TPA, if known. The demand letter includes information on the claims repayment demanded and the claims detail. The demand letter explains how to resolve the debt, either by repayment or presentation, and documentation of a valid defense. An employer may authorize an insurer or TPA to respond on its behalf, but may not transfer responsibility for a debt to the insurer or TPA. Additionally, if the insurer or TPA submits a check or a response but has not submitted documentation establishing its authority to act on behalf of the employer to resolve the debt, responses will only be addressed to the employer. Please note that in some instances an insurer or TPA has a defense that does not necessarily absolve the employer of responsibility for the debt (e.g., the insurer or TPA did not cover/administer at the time of the claim).

For more information on the processes used by the CRC to recover mistaken primary payments, click the Group Health Plan Recovery link.

The MSP statute and regulation further preclude Medicare from paying for a beneficiary’s medical expenses when payment has been made, or can reasonably be expected to be made under workers’ compensation law or plan of the United States or under an automobile or liability insurance policy or plan (including a self-insured plan) or under no-fault insurance. However, the MSP provisions allow Medicare to pay conditionally for a beneficiary’s covered medical expenses when the third party payer does not pay promptly. If conditional payments are made, Medicare has the right to recover those payments. The BCRC is responsible for processing recovery cases involving liability insurance (including self-insurance), no-fault insurance and workers’ compensation where Medicare is seeking repayment from the beneficiary. The CRC is responsible for pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity.

For more information on the processes used by the CRC to recover conditional payments, see the Insurer NGHP Recovery page.

Mandatory Insurer Reporting

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (P.L.110-173) sets forth new mandatory reporting requirements for GHP arrangements and for liability insurance (including self-insurance), no-fault insurance, and workers' compensation (also referred to as Non-Group Health Plans or NGHPs). See 42 U.S.C. 1395y(b)(7) & (8). The provisions were implemented January 1, 2009 for GHP arrangements, and July 1, 2009 for NGHP insurers.

For an overview of the Mandatory Insurer Reporting process, including registration and reporting requirements, please click the Mandatory Insurer Reporting for Group Health Plan (GHP) link or the Mandatory Insurer Reporting for Non-Group Health Plan (NGHP) link.