The Centers for Medicare and Medicaid Services (CMS), charged with protecting Medicare’s fiscal integrity, works to recover payments made by Medicare that are the responsibility of non-group health plans. While CMS has not always been aware of all such situations in the past, 2007 legislation introduced mandatory non-group health plan reporting requirements, which should increase CMS awareness. Reports made by non-group (individual) health plans about the Medicare Secondary Payer (MSP) process prompted a delay by CMS in the commencement of mandatory reporting.

In a new report to Congress, Additional Steps Are Needed to Improve Program Effectiveness for Non-Group Health Plans, the U.S. Government Accountability Office (GAO) examined how implementation delays affected Medicare Secondary Payer contractor workload and payments as well as Medicare savings. The report also looks at key challenges within the Medicare Secondary Payer (MSP) process along with steps being taken by CMS to address those.

MSP contractor payments and Medicare savings increased during initial mandatory reporting implementation, though total Medicare savings could take years to establish. GAO pinpointed key challenges related to contractor performance, demand amounts, CMS communication and guidance, and some mandatory reporting aspects. CMS took steps to address some of those challenges related to:

  • Timeliness of Medicare contractors – the Medicare Secondary Payer Recovery Contractors (MSPRC), and Workers’ Compensation Review Contractor (WCRC).
  • Demand amount timing, Medicare demand amounts from liability settlements, and the cost-effectiveness of recovery efforts.
  • Certain aspects of mandatory reporting including Medicare beneficiary determination, injury diagnostic code supply, and reporting all liability settlement amounts.
  • Guidance and communication challenges around MSP process, beneficiary rights and responsibilities, and guidance on Medicare set-aside arrangements.

GAO provided recommendations for improving the MSP program. Those include decreasing the non-group health plan reporting burden, improving recovery cost-effectiveness, and improving non-group health plan stakeholder communications.

To read or download the full report, click here (PDF).