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MSPRC to Offer Pre-Settlement Final Demands

The MSPRC recently announced a new option which essentially creates pre-settlement Final Demands for Medicare Liens.  From its website:

New Option to Self-Calculate Your Conditional Payment Amount

On February 21, 2012, the Centers for Medicare & Medicaid Services (CMS) will implement an option that allows certain Medicare beneficiaries to self-calculate Medicare’s final conditional payment amount prior to settlement. A full explanation, including instructions on how and when to elect this option can be found by clicking here.

The information provided includes eligibility criteria for this process, instructions on how to self-calculate the final conditional payment amount, CMS’ review process, tips, and an illustrative example for completing this new process.

CMS will continue to improve and refine this process. Therefore, we welcome your input and comments at a future teleconference.

When Does Self-Calculation Apply?

  • The settlement is for a Liability file only (no PIP, Med-Pay, Workers’ Compensation, or other No-Fault insurance);
  • The total settlement value is less than $25,000.00;
  • The settlement is for a Trauma-based injury (no ingestion, exposure, or medical implants and therefore no products liability or mass tort type cases);
  • The date of incident is more than 6 months ago;
  • The beneficiary demonstrates that treatment is complete and no further treatment is expected through:
    • A written physician attestation; or,
    • A written certification from the beneficiary that:
      • No medical treatment related to the case has occurred for at least 90 days; and,
      • No further care is expected.


Is Anything Else Required?

Yes.  The beneficiary must waive his right to appeal the lien.  The right to a waiver remains.


But This is a Self-Calculated Conditional Payment – How Does it Become a Pre-Settlement Final Demand?

First you need a Conditional Payment Letter (“CPL”) from the MSPRC.  That process takes about 90 days starting with the reporting to the COBC.  Then, you need to mark that CPL with Ys and Ns referring to what does apply (Y / Yes) and what does not apply (N / No).  Amazingly, the MSPRC then wants you to look at mymedicare.gov and add any claims that are related to the case.  Continuing on, the MSPRC requires model language for the option.  Finally, you will attach the attestation (physician or beneficiary certification).

At this point you’re halfway to a Final Demand.  Sixty days later the MSPRC will provide a new “Final Conditional Payment Amount.”  This letter will either agree or disagree with your calculation; however, it will be considered the final conditional amount for 60 days.

Assuming you settle within the 60 days you have one more step: Prepare a final settlement detail as you would for a normal Medicare lien case, but include the first and last page of the settlement agreement, and, include the MSPRC letter agreeing or disagreeing with the self-calculation.  The Final Demand will be issued within 20 days.

This whole process appears to be 170 days.  Even the MSPRC suggests it will take five months.


Is it Worth My Time?

Probably not.  It applies to very few cases and seems to be more work than the average lien.  Our next post will analyze the pros and cons of Medicare’s Self-Calculated Final Conditional Payment Amount.


Ryan J. Weiner
Co-Founder Lien Resolution Services
Twitter: @LienResolve
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 “MSPRC to Offer Pre-Settlement Final Demands

  1. […] most obvious benefit of Medicare’s new Self-Calculated Payment Amount is that you can finally know the lien when you settle.  No more blindly settling when you only […]

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