Protecting Medicare’s Interests Medicare is always secondary to workers compensation insurance. Future medical payments are protected by Medicare Set-Aside arrangements (2001). Past payments are covered by this new reporting so that Medicare can recover any $$$ it paid that we should have paid.
Conditional (Past) Payments made by CMS Mandatory quarterly reporting of all Medicare eligible claimants on the issues of: ORM TPOCs Provides CMS the ability to query their files and determine if they paid something that a primary payer should have paid.
Conditional (Past) Payments made by CMS Mandatory quarterly reporting of all Medicare eligible claimants on the issues of: Ongoing responsibility for medicals (ORM) Total payment obligation to claimants (TPOCs) Provides CMS the ability to query their files and determine if they paid something that a primary payer should have paid.
Text Translations 411 511 AYS AYT MOS LEMENO
Who must report? The Responsible Reporting Entity for a claim (including but not limited to): The insurance carrier where there is policy coverage. The self-insured entity where the SI makes payments directly to the claimant. The excess or reinsurance carrier where the carrier makes payments directly to the claimant. http://www.cms.gov/MandatoryInsRep/Downloads/ AlertWhoMustReportrev052610.pdf
Medicare Reporting Process Monthly query file to determine which of our claimants are Medicare eligible. SSN or HICN: REQUIRED First initial Last name (6 characters) DOB Gender
Medicare Reporting Process Quarterly reporting of data on Medicare eligible claimants Where ongoing responsibility for medicals exists as of Jan 1, 2010 On claims with settlements, judgments or awards on/after October 1, 2010.
Penalties for Non-Compliance Failure by a Responsible Reporting Entity (RRE) to timely report a claim to CMS has a penalty payment of $1000 per day per claim. Penalty collections have already been allocated to the SCHIP program.
Text Translations NOYB BFF BFFNMW CD9 CM
Challenges/Translations/Training Missing SSN or DOB Date of accident for Occupational Diseases Flagging TPOCs Date of a TPOC Settlement for solidary obligors ICD-9 Coding (covered/alleged/released) Denied Claims RPO Claims
Missing SSN or DOBs At claim intake? During the claim investigation. Form recommended by CMS. Documentation in the claims file. http://www.cms.gov/MandatoryInsRep/Downloads/NG HHICNSSNNGHPForm.pdf
Date of Accident for Occupational Diseases Identifying OD claims and CT claims. Date of last injurious exposure is the date of accident in LA. CMS: Date of first exposure After the date of Medicare eligibility (which they won’t give us) Which could be with a different employer, with no obligation to us, insured by another carrier….
Flagging TPOCs Payments to the claimant (but not all payments) Settlements, judgment, award, or other payment in addition to/apart from ORM. Structured settlement (total payout from the annuity). Identify by Payment Codes?
TPOC Dates Defined in Field 100 of the Claim Input File Detail Record. Date payment obligation was signed if court approval not required (not necessarily the date of the check). Date of court approval (on judgments and consent judgments). Do you have these dates in your claims system?
TPOCs and Injuries Covered, Alleged, or Released. New to User Guide 3.1 When claims are settled, ICD-9 coding must cover any injuries covered, alleged, or released. Who tracks injuries alleged? http://www.cms.gov/MandatoryInsRep/Downloads/NG HPUserGuideV3.1.pdf
Settlement for Solidary Obligors Seriously? Really? Report the total amount of the settlement paid by all parties. Even though you don’t have that payment info in your system, and you are not issuing those checks. In LA: Borrowing employer or direct/statutory employer situation where the settlement is partially funded by another employer/insurer.
Text Translations GL2U GTG SUP IDK JK
ICD-9 Coding For Claims with ORM One ICD-9 code, per covered body part, up to 5. After 5, provide the codes if they are available/applicable (up to 19). For 1/1/11 reporting, CMS will accept Versions 27, 28, & 29. Training….. Conversions to ICD-10 and training down the line.
ICD-9 Coding For Claims with TPOCs One ICD-9 code, per covered, alleged, or released body part, up to 5. After 5, provide the codes if they are available/applicable (up to 19).
Denied Claims ORM = No, right? Wrong. Paying initial medical treatment without an admission of liability. Paying for an evaluation because your statute requires it. CMS will assume ORM from date of accident until the ORM term date.
RPO (Reporting Purposes Only) or Incident Only Claims Notice of the claim Carrier must have notice to query the file. The employer assumes responsibility as the RRE if they are paying the claim and do not report. Clmt (65) reports a knee injury to employer, but does not seek medical care immediately. Claim is submitted to carrier as an RPO. Is this okay? The employee sees the doctor a week later and files with Medicare. Is this okay?