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Workers' Compensation

CMS Announces New "Self-Calculated Final Conditional Payment Amount" Option for Certain Liability Claims

  By Mark Popolizio, Esquire
Section 111 Senior Legal Counsel
Crowe Paradis Services Corporation
The Centers for Medicare and Medicaid Services (CMS) will implement a new Self-Calculated Final Conditional Payment Amount option beginning in February 2012 through which Medicare’s “final” conditional payment amount may be obtained prior to certain liability settlements, judgments, awards, or other payments.  This option will be limited to liability cases involving physical trauma injuries where treatment has been completed and which otherwise meet CMS’ qualifying criteria as listed below.
Based on the limited information released thus far, the parameters and requirements of CMS’ Self-Calculated Final Conditional Payment Amount option can be outlined as follows:
Which Cases Will Qualify?
As referenced, this new option will only apply to certain liability cases.  In order to qualify for this option, CMS states that ALL of the following criteria must be met:
  1. The liability insurance (including self-insurance) settlement will be for a physical trauma based injury (the settlement does not relate to ingestion, exposure, or medical implant);
  2. The total liability settlement, judgment, award, or other payment will be $25,000 or less;
  3. The date of incident occurred at least six months before the beneficiary or his representative submits his proposed conditional payment amount to Medicare; and
  4. The beneficiary demonstrates that treatment has been completed and no further treatment is expected either through a written physician attestation or by certifying in writing that no medical treatment related to the case has occurred for at least 90 days prior to submitting the proposed conditional payment amount to Medicare.
How Will it Work?
The beneficiary or his/her representative “will calculate the amount of Medicare's conditional payment amount using information received from the Medicare Secondary Payer Recovery Contractor (MSPRC), the MyMedicare website, or other claims information available to the beneficiary.
Thereafter, the MSPRC will review the submitted amount.  If the MSPRC determines that the submitted amount is accurate, it will then respond by providing Medicare's “final” conditional payment amount within 60 days.  In order to “secure” the final conditional payment amount, the beneficiary must settle his/her case within 60 days after the date of Medicare's response.
CMS’ Next Steps & Related Information
CMS is expected to post detailed instructions on how to use this new process on the MSPRC website ( by January 15, 2012.  CMS further indicates that it “will leverage existing processes to the greatest extent possible.”  However, the agency did not provide any further information on this point.   
As for other matters, it is interesting to note that CMS describes this new process as “an initial step to provide beneficiaries and their representatives with Medicare’s conditional payment amount prior to settlement.”  CMS also states that it plans on expanding this option in the future “as it gains experience with this process.”
Crowe Paradis Services Corporation will continue to monitor developments in this area and will update the claims industry accordingly as additional information is obtained. 
Mark Popolizio, Esquire is Section 111 Senior Legal Counsel for Crowe Paradis Services Corporation.  Mark is a nationally recognized leader in MSP compliance.  He has authored numerous articles on MSP issues including MMSEA Section 111 reporting, MSAs and conditional payments.  Mark is a regularly featured presenter at national seminars and other industry events.  Mark can be reached at or (786) 459-9117.