The Step-by-Step Guide to Obtaining a ‘Conditional Payment Letter’ (CPL) and How to Satisfy the Medicare Lien
By George “Boo” Hollowell, Esq.

My legal assistant, Amy Pieroni, and myself, have spent a number of hours dealing with the Medicare Contractors to resolve their claim/lien. Thus far, we have found the following guide is the most successful method to finally satisfy Medicare and the Courts.

KEY:

 

COBC= Coordination of Benefits Contractor

COBC Telephone:

COBC Address:

1-800-999-1118

Medicare- Coordination of Benefits

 

P.O. Box 33847          

Hours of Operation:

Detroit, MI 48232-5847

Mon-Fri 8 a.m.-8 p.m. (ET)

 

 

MSPRC=Medicare Secondary Payer Recovery Contractor

 

CPL=Conditional Payment Letter

MSPRC Fax Number:

MSPRC Address:

(405) 869-3309

MSPRC

 

P.O. Box 138832

MSPRC Telephone Number:

Oklahoma City, OK 73113

(866) 677-7220

 

1. When you agree to accept a workers' compensation, personal injury and/or wrongful death client, obtain the following information in order to protect your client and yourself from future liability for Medicare payment(s) made on behalf of your client:
a. Client's name, last known address, and phone number.
b. Type of Claim: (Liability Insurance, No-Fault Insurance, or Workers' Compensation)
c. Client's date of birth and gender.
d. Client's date of death (if applicable).
e. Client's Health Insurance Claim Number (HIC#), Medicare Number, and Social Security Number.
f. Date of incident/injury/illness.
g. A description of incident/injury/illness. In addition, if you are familiar with ICD-9 codes, include the code with each incident/injury/illness for best results. (ICD-9 Code site we use: www.ICD9data.com)
h. Name and address of Workers' Compensation carrier (if applicable).
i. Name and address of the legal representative.
*"Client" will be the same whether for a workers' compensation claim, injury claim, and/or wrongful death claim.*

2. Once you obtain this information, initiate the "Conditional Payment Letter" (CPL) request process by following these instructions:

a. Go to www.msprc.info and first "TOOL KITS"; in the next window, click on "Attorney Tool Kit".
1. "Attorney Tool Kit" - You will find the title "Consent to Release Model Language, " click on this title and print. On page 2 of 2 you will find the actual "Consent to Release" that must be signed by your client or, if deceased, by his/her personal representative; hold this document for use at a later time. You will also find the title, "Correspondence Cover Sheet" in the same window. You should print this document and hold it for use at a later time. Next, you will find the title "Proof of Representation Model Language" in the same window. You should print this form which consists of two pages. The actual “Proof of Representation” form is found on page two.

b. Contact the COBC by calling 1-800-999-1118.
CAVEAT: You must contact COBC in order to have your client included in the system. You cannot contact the MSPRC without having completed this step!

1. The information you initially obtained from your client needs to be readily available. Follow the prompts; once a representative is on the line, proceed by giving him/her the information you have obtained from your client. In order to expedite the process, make sure you document in your notes the person you spoke with, the date, and the time.

2. Once you have given the COBC representative your client's information, he/she will inform you the information will be forwarded to MSPRC, and this information will be in their possession within three to four business days.

3. You must wait three to four business days before sending an executed "Proof of Representation" or "Consent to Release" form to M PRC either by mail or fax. We use the "Proof Of Representation" form because it is signed by both the beneficiary and the attorney. The address and fax number are listed above.

4. The COBC representative will inform you that all parties associated with your client's case shall receive a "Rights and Responsibilities" letter. You should receive the "Rights and Responsibilities" letter from the MSPRC within three weeks of initially contacting the COBC.

5. If you do not receive the "Rights And Responsibilities" letter within three weeks of contacting the COBC, call the MSPRC at 1-866-677-7220. Follow the prompts until a representative is on the line. (Usually there is an "on hold" period of twenty minutes minimum.) Inform the MSPRC representative that you have not received the "Rights and Responsibilities" letter and that you spoke with a specific COBC representative at a certain date and time. (See b. 1.) The representative will instruct you as to what you must do to receive this letter. If the MSPRC needs any additional information and/or documentation, they will first attempt to contact you by phone; however, if they are unsuccessful, they will send you a letter.

6. You should receive the "Conditional Payment Letter" within 65 days of the date of the "Rights and Responsibilities" letter. The “Conditional Payment Letter" includes the amount MSPRC claims to be related. Further, they will attach a "Payment Summary Form" (click here for an example). It is at this point you may dispute the amount MSPRC claims is related.

a. Prepare a "Related/Unrelated Worksheet Summary" based on the "DIAGNOSIS/ICD" codes listed on the "Payment Summary Form(s)." After you prepare your summary, you will then decide if you want to dispute the MSPRC claim set out in the CPL.

b. If you are satisfied with the amount in the CPL, then fax a "Final Settlement Detail Document” (also found on the MSPRC website under "Attorney Tool Kit" as in 2.) a) to MSPRC requesting a Final Demand Letter be generated. You should include an executed Settlement Agreement, Employment Contract, Expense Sheet, Disbursement Sheet (if applicable), and the "Procurement Cost" Sheet (see number 3 below). In the "Final Settlement Detail Document", make sure you reduce the amount owed MSPRC by the "Procurement Cost.” You should receive a Final Demand Letter from MSPRC within 30 to 60 days. You must send a check within sixty days of the date on the Final Demand Letter or interest will be charged from the date of the Final Demand Letter.

c. If you are dissatisfied with the amount demanded in the CPL, send your "Related/Unrelated Worksheet Summary" (click here for an example) to the address set out in the CPL and include all documents, medical records, depositions, and opinions that will support your position as to what is unrelated. You may want to use portions of the Defendant(s) expert opinions and/or depositions to support your position, but be careful. You will receive a response within 30 to 60 days.

d. Once you receive this response from MSPRC, if you are dissatisfied, then you will Appeal in accordance with the instructions in said letter.

3. Procurement Costs are set out in accordance with 42C.F.R. Part 411.37 as follows:

 

 

EXAMPLE

Line 1

Amount of Settlement

$100,000

Line 2

Medicare Payments

$12,142.61

Line 3

Attorney’s Fees

$40,000

Line 4

Expenses

$24,903

Line 5

Line 3 plus Line 4

$64903

Line 6

Line 5 divided by Line 1

65%

Line 7

Line 2 times Line 6

$7,892.69

Line 8

Line 2 minus Line 7

$4,249.92

Based on this calculation, the amount of your related claim is $4,249.92. This is your reduced lien amount.

Remember that you cannot get a Final Demand Letter until you settle or get a judgment, but you can get your CPL early and be ready to request the Final Demand Letter immediately upon completing the case.

If you have any questions or need assistance, call 1-800-898-0995 and ask for my legal assistant Amy Pieroni, or me.