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Medicare: How to Read Conditional Payment Letters

The MSPRC timeframe for a Conditional Payment Letter is approximately 80 days after reporting to the COBC.  But remember, the MSPRC can change this timeframe whenever it sees fit, and may do so next week, during a MSPRC Webinar.

The Conditional Payment Letter (“CPL”) appears daunting to many attorneys.  There are codes, lines, dates, and of course, large payment amounts.  Does the MSPRC make mistakes?  Yes.  Does the MSPRC over-bill? Yes.   Plaintiff and defense attorneys alike should review these CPLs.  A lower Medicare lien can save both sides money and allow the plaintiff to take home a larger portion of the settlement.  But what do these three, four, and five digit codes mean?

All hospitals and medical providers bill using ICD-9 codes.  On a Medicare Conditional Payment Letter, the codes show up without any punctuation.  But, no code is technically larger than 999.99.  So if you see 25000, it’s really 250.00 (coincidentally, a diabetes code, which should not be part of any lien).  You can find ICD-9 dictionaries online.

Unfortunately, Medicare and the MSPRC allow providers to bill up to five codes for one payment.  As a result, sometimes unrelated codes remain part of the lien.  You will have to write a lien dispute, or, as most attorneys attempt, negotiate with Medicare.

Auditing and translating ICD-9 codes is extremely time consuming.  Disputing, negotiating, and appealing the liens can take even longer – especially if you don’t know what you’re doing.  You should consider hiring an outside firm for lien resolution.

Ryan J. Weiner
Co-Founder Lien Resolution Services
This Blog/Web Site is made available by the publisher for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice. By using this blog site you understand that there is no attorney client relationship between you and the Blog/Web Site publisher. The Blog/Web Site should not be used as a substitute for competent legal advice from a licensed professional attorney in your state.

About Ryan J. Weiner

Co-Founder of Lien Resolution Services, LLC, a national healthcare lien resolution firm. Our goal is to assist in the fair administration and resolution of healthcare liens on personal injury cases. Please visit our website for more information: www.lienresolutionusa.com.

One comment on “Medicare: How to Read Conditional Payment Letters

  1. […] Audit the payment summary and ICD-9 codes listed.  This begins your Medicare “negotiation” process. […]

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