Conditional Payment Reimbursement Services

With close to 65 million beneficiaries today, Medicare has become the second largest health insurance program in the United States, second only to Medicaid. One out every 5 Americans is insured by the Medicare system. Whether thru Part A (hospital coverage), Part B (physician services), Part C (advantage organizations) or Part D (prescription plans), all components of Medicare are entitled to reimbursement should Medicare make a payment where a primary payer or applicable plan is responsible for same. Cattie & Gonzalez offers conditional payment reimbursement services in each of these areas

Close to 60% of Medicare beneficiaries receive their hospital and physician services through traditional Parts A and B coverage. We will verify eligibility and obtain confirmation of payments made by Medicare. Upon receipt of correspondence detailing same, we review the itemization meticulously. Our audit considers whether everything payment listed is/not related to the claim. If payments are not related to your claim, we dispute those charges, using medical and legal documentation to support our conclusions. Throughout the course of the life of the case, we continue to request updated conditional payment letters (reviewing most recent itemization and disputing unrelated charges) until you resolve the case. Upon resolution of the claim, we ask for a final demand and provide you with detailed instructions of when, how, and where to send payment to Medicare.

Over forty percent (40%) of all Medicare beneficiaries today receive their coverage through a Medicare Advantage Organization (MAO) offering Medicare Part C coverage. Once we identify the MAO, we reach out to negotiate and minimize the our client's repayment obligation. While some MAOs handle their own recovery, others will engage recovery agents to work on its behalf. Whether dealing directly with the MAO or with a recovery agent, on behalf of our client, we request an itemized listing of all payments, analyze same, and dispute unrelated charges. Should the client disagree with the final amounts allegedly owed to the MAO, we pursue and exhaust all available avenues of appeal.

Over 80% of all Medicare beneficiaries today receive their prescription coverage through a Medicare Prescription Drug Plan (PDP) offering Medicare Part D coverage. If the Medicare beneficiary has purchased prescription drug coverage through a stand-alone PDP, then once we identify the PDP, we reach out to obtain a copy of the prescriptions provided by and paid for by the PDP. We then analyze such payments to determine if they are related to the claim. Whether dealing directly with the PDP or with a recovery agent, we dispute, on behalf of our client, unrelated charges. When we have reached an agreement on the reimbursable medications and amounts, we will request a finalized bill in writing from the PDP and will provide our client with specific instructions on when, how, and where to send payment. Should the client disagree with the final amounts allegedly owed to the PDP, we pursue and exhaust all available avenues of appeal.

Whether coming from the Commercial Repayment Center (CRC) in no-fault or work comp claims in which the primary payer has accepted ongoing responsibility for medical, or from the Benefits Coordination Recovery Center (BCRC) in automobile, medical malpractice, nursing home, products, slip and fall, trucking, and other general liability claims in which the primary payer has not accepted ongoing responsibility for medical, we handle all CRC and BCRC conditional payment issues at all levels, understanding the differences between these government contractors processes, policies, and procedures. Upon receipt of a conditional payment notice (CPN) from the CRC, or a conditional payment letter (CPL) from the BCRC, we review the itemization meticulously. If payments are not related to your claim, we dispute those charges on a timely basis, using medical and legal documentation to support our conclusions. On CPLs coming from the BCRC, we continue to request updated conditional payment letters repeatedly reviewing the most recent itemization and disputing unrelated charges until you resolve the case, at which point we ask for a final demand and provide you with detailed instructions of when, how, and where to send payment to BCRC. On CPNs coming from the CRC, we dispute unrelated charges within 30 days, redetermination within 120 days, and reconsideration within 180 days, at which point we provide you with detailed instructions of how, when, and where to send payment to CRC

Cattie & Gonzalez offers clients the ability to leverage Medicare's portal only pre- settlement “final” conditional payment process to limit the amount ultimately owed back to Medicare for conditional payments. This service is unlike anything offered by anyone else in the country helping clients resolve conditional payments. When you take the right procedural and timely steps in advance of settlement, you can mitigate the conditional payments owed back to Medicare. Our most sophisticated clients often choose this service because of the great results we obtain when using this portal only, pre-settlement process. Strict adherence to specific time frames and procedural requirements are a must in order to take advantage of these unique opportunity to significantly reduce your Medicare conditional payment responsibility.

In cases where you disagree with the amount of Medicare’s final demand, you have options. We understand the detailed steps involved with the appeals process as well as the strict time standards that must be met in order for your appeal to be heard on the merits. That work may include Request for Redetermination, Request for Reconsideration, Request for Hearing before an Administrative Law Judge (ALJ); Request for Review by the Medicare Appeals Council; and Legal action in United States District Court. As attorneys who have handled thousands of conditional payment cases, Cattie & Gonzalez fully comprehends, understands and actively utilizes the complete Medicare appeals process on behalf of our clients when necessary to achieve the right result in a case. Depending on the case, the facts, and the issue at hand, we lead our clients through a sophisticated array of options on how to best prove our argument through testimony of the claimant and his/her family members, testimony from active participants in the litigation of the claim, consequential and significant evidence born from the litigation of the case, and written documentation and communication between the parties and the various medical experts who provided care throughout the case.