CMS Conditional Payment Recovery Changes

As you may have heard, there have been significant changes that have taken place with regard to conditional payment recovery efforts by the the Centers for Medicare and Medicaid Services (CMS). We are all aware that this important aspect of Medicare Secondary Payer Compliance may result in penalties or litigation if conditional payments are not properly addressed by reimbursement or dispute.

In October 2015, CMS created the Commercial Repayment Center (CRC), a contingency fee based private subcontractor of CMS, to pursue recovery of conditional payments in cases where the Employer/Carrier has been identified as the responsible party via Section 111 MIR Reporting. The CRC will now be pursuing conditional payment recovery in cases where there is ongoing responsibility for medical benefits (ORM). This is a departure from previous CMS policy, which historically pursued recovery for conditional payments at the time of settlement.

For the claim professional, it’s important to know that the CRC will be issuing time-sensitive “Conditional Payment Notices” or CPN’s. The critical task for the insurance carrier or claim administrator will be to review the CPN immediately in order to decide whether to dispute the alleged conditional payments. Please be aware that if the dispute is not filed within 30 days of the date of the CPN, then the CRC will issue a demand for payment.

In addition to mandatory response deadlines, the CRC is also requiring additional documentation in the form of the Proof of Representation/Letter of Authority for vendors who pursue recovery efforts on behalf of the self-insured employer, insurance carrier or third party administrator.


Axiom National is well positioned to assist you by appropriately disputing Conditional Payment Notices. Should you receive a CPN that you wish to dispute, please refer to our office as soon as possible to ensure that the dispute is filed in a timely manner.

For questions or additional information please contact Geoffrey Hudson at 1-888-826-6496, or

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