Case Study: CMS

The firefighter’s employer received a demand letter from the Centers of Medicare & Medicaid Services (CMS) Commercial Repayment Center (CRC) Statement of Reimbursement for conditional payments in the amount of $253,174.81 for the firefighter’s medical treatment.

Besides the demand letter, the only documentation that the employer received was a list of treatment providers, treatment dates, ICD codes, and charges.

The firefighter’s Employer and Intercare could not access medical records that were unrelated to the firefighter’s workers’ compensation claim, so the PBM team analyzed the ICD codes and medical guidelines to determine the type of procedures and the correlation to our claim.

The team discovered that of the 12 dates for services and meetings with providers listed in the CRC Statement, only three were related to the firefighter’s workers’ compensation injury. The other nine were for unrelated conditions. The team successfully argued that only $360.72 of the $253,174.81 was related to the claim.

CMS agreed and ruled that the Employer was not responsible for the full amount resulting in a 99.8% ($252,814.09) savings.