Surviving MMSEA Section 111 June 30, 2009

1 Marsh | ASHRM Today’s Panelists Krishna Lynch, RN, BSN, MJ, CPHRM - Moderator Director, Risk Management Resources ASHRM Diane Wilkerson HealthCare Claims Consultant Marsh Risk Consulting Barbara Balas Quality Management Director Warren Hospital Clare Bello President and CEO Vertical Claims Management

2 Marsh | ASHRM Goals and Objectives  Know the Impact of MMSEA Section 111 – Scope of the Legislation: GHPs and Non GHPs – How to identify the NGHP claims which qualify for mandatory reporting – Landmines and Challenges  Prepare a Successful Registration – Choosing the RRE(s) – Three key Steps – Lessons Learned  Learn the scope of the reporting process – When to Report – What to Report – How to Report

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4 Marsh | ASHRM MMSEA Section Where did it come from?  Social Security Act of Medicare and Medicaid – Primary payer except for black lung disease and veterans – Medicare was reimbursed for workers compensation injuries  Medicare Secondary Payer Statute – 1980 – Focus on Medicare Beneficiaries (MBs) – Secondary when another payer responsible for injury or illness – Super Lien – extensive right of recovery back to payer – Can collect double damages + interest for cost shifting  Section 111 MMSEA – Does not change any provisions of MSP 1980 – Adds reporting structure, process and penalties for non-compliance – Mandates data collection to implement MSP recovery  Group Health Plan enrollees -identify MBs covered by GHPs  Non Group Health Plan claims paid – identify MB claimants

5 Marsh | ASHRM MMSEA Section Two Part Focus  Group Health Plans - Primary Payer – Report employed/enrolled active covered individuals  Ages 55 – 64 employee and family members (2009, 2010)  Age 65 or more - employee or covered by employed spouse  ESRD – kidney dialysis or transplant (after 30 months)  Under age 65 and certain disabilities in LGHP – CBC determines if Medicare beneficiary and who is primary – Report self-paid liability claims per NGHP format  Self Insured Retentions, Deductibles paid directly to claimant  Implementation Timeline – January 1, GHPs began reporting if VDSA/VDEA prior – April 1, new GHPs register who were not VDSA/VDEA – April 1, 2009 to July 1, 2009 – Testing period for new GHPs

6 Marsh | ASHRM MMSEA Section Two Part Focus (cont’d)  Non Group Health Plans - Primary Payer (Liability, Auto No-fault, Workers’ Comp) – Must report partial payments, settlements, judgments, or awards to Medicare beneficiaries for bodily, personal, or occupational injury  TPOCs - as of 1/1/2010  ORMs - as of 1/1/2009 – Penalties for late reporting - $1,000/day/claimant  Implementation Timeline Extended - as of May 11, 2009 – Registration: May 1, 2009 thru September 30, 2009 – Testing: Begins July 1, 2009 – register first – Queries: Begins July 1, 2009 – register/test first – Claim File Upload: Testing begins January 1, 2010 – Production: Data reporting begins April 1, 2010

7 Marsh | ASHRM MMSEA Section Achieving Compliance  Compile an Open Claim Inventory – All coverage lines: liability, no fault, work comp  Commercially insured or self insured  Involve injury requiring medical care  Verify Insurance Program Design and Risk Retention Levels – Per policy year per coverage line  Self Insured Retentions and Deductibles – Determine current claims administrator/RRE for open claims  Commercial insurance carriers  Onshore/Offshore Captives and RRGs  Self-administered entities:  Evaluate Information Management Systems – Self-administered entities – various layers  Capacity to add 130+ data fields for compliant reporting?  Self report or select a reporting agent with compliant solution?

8 Marsh | ASHRM Just Who is the RRE?  CMS Defines an RRE as: – The entity who  Pays a settlement, award, judgment, or other payment  Has responsibility for ongoing medical payments  To a claimant who is a Medicare beneficiary – Simply stated  Whoever pays the claimant is responsible to report - TPOCs on and after January 1, ORMs beginning on and after January 1, 2009  Who is the RRE if an entity has a – Self Insured Retention  The entity if it self-insures/pays within SIR – Deductible  The entity if it pays deductible directly to the claimant  The insurer if it pays deductible directly to claimant and is reimbursed by the entity

9 Marsh | ASHRM What about RREs for Captives and Risk Retention Groups?  Captive with Offshore Domiciles – Most are reimbursement agreements – The named insured pays claims onshore and captive reimburses – The RRE is the named insured onshore  Captives with Onshore Domiciles – The named insured is an RRE when it uses SIR to pay the claim – The captive is an RRE when it pays the claim above the SIR  Risk Retention Groups – Domiciled onshore and contain insuring language – Pay claims on behalf of its members – RRG is the RRE

10 Marsh | ASHRM MMSEA Section Compliance Landmines and Challenges  Insurance Program Issues – Policy year structures change – Carriers and service partners – Multiple RREs may be required  Self Administration Challenges – Claim management staff training and workflow process – Increased data collection requirements – still on Excel? – HICN preferred to Query for MBs; SS # required if not provided – Reporting agent due diligence and oversight - RREs pay penalties – Medicare liens and impact on claim reserves and settlement  Conditional Payment Claims and Settlements – Prepare to respond for past payments and future needs at settlement – If not, who will they target - Claimant, Attorney, or Payers?

11 Marsh | ASHRM MMSEA Section Translation Key  CMS : Centers for Medicare and Medicaid Services  COBC : Coordination of Benefits Contractor  COBSW: Coordination of Benefits Contractor Secure Website  EIN: Employer Identification Number  ESRD: End Stage Renal Disease  HICN : Health Insurance Claim Number  MIR : Mandatory Insurer Reporting  MMSEA: Medicare, Medicaid, State Children’s Health Insurance Plan Extension act  MSA : Medicare Set Aside  MSP : Medicare Secondary Payer Statute  MSPRC: Medicare Secondary Payer Recovery Contractor  ORM: Ongoing Responsibility for Medical  RRE: Responsible Reporting Entity  RRE ID : Responsible Reporting Entity Identification Number  SCHIP: State Children’s Health Insurance Program  SSDI: Social Security Disability Income  TIN: Taxpayer Identification Number  TPA: Third Party Administrator  TPOC : Total Payment Obligation to Claimant  VDSA : Voluntary Data Sharing Agreement/  VDEA : Voluntary Data Exchange Agreement  WCMSA : Workers’ Compensation Medicare Set-Aside Arrangement

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13 Marsh | ASHRM Our Program  Warren Hospital – 214 bed acute care, not for profit, community hospital – Northwest New Jersey  Self-Insured one year – Liability – Excludes auto and workers’ comp  Hospital Risk Retention Group – Liability – Excludes auto and workers’ comp  Physician Risk Retention Program

14 Marsh | ASHRM Choosing our RRE and How Many IDs  How did we plan for Section 111? – Researched Section 111 – Began planning for actual implementation May 2009 – Vice President of Legal Affairs and Chief Financial Officer involved in planning – VCM our TPA provided information on Section 111 – Would we have an agent report for the programs  How did we determine how many ID numbers we would need for the CMS Reporting compliance? – Each of three programs distinctly different each would require an ID number  What information did we need to gather before beginning the registration process? – Who would be the Authorized Representative and sign the CMS contract – Corporate address associated with the TIN for entity and agent – TIN for the entity registered and agent – Identify lines of business

15 Marsh | ASHRM Registration Three Step Process  May 1, 2009 – September 30, 2009 (  Authorized Representative – Establishes RRE and Account Manager for each RRE ID # needed – Receives written letter from CMS with RRE ID#  Account Manager – After receiving RRE ID# and PIN, completes on-line registration process  Signed documentation to and from CMS

16 Marsh | ASHRM Registration - Step 1 Authorized Representative  RRE Entity Information – Entity Name – Address – Tax ID Number  Authorized Representative Information – Name – Address – Contact Information  Instant RRE ID Number – Authorized Representative registered May 19, 2009 and in 14 days, on June 2, 2009 received letter with ID# of Physician RRG and PIN to begin step 2

17 Marsh | ASHRM Registration – Step 2 Account Manager  Step 2 was performed on June 2, 2009  Account Manager contact Information  Additional Information you need to have to finish this phase: – Line of Business of RRE – Estimated number of files to be reported to CMS – Whether you will use an agent for reporting  Reporting agent contact information with TIN – Method for upload of data to CMS – Whether you will use the COBC encryption wrapper software – File transmission method

18 Marsh | ASHRM Registration – Step 3 Data Exchange Agreement  Step 2 was completed June 2, 2009 and on June 10, 2009 the profile report and data exchange agreement was received from CMS  Authorized Representative signed data exchange agreement documentation and returned it to CMS

19 Marsh | ASHRM Registration Experience  Registering with CMS is not difficult if you have the necessary information available  Unclear why we only received one registration notice – Physician Risk Retention Group - Plan to research further

20 Marsh | ASHRM Registration Tips  Authorized Representative Step – Be sure that the name entered for entity being registered is exactly the same as the name used with the IRS for Tax ID Number  Can call IRS at (800) for assistance – NAIC code field – if you don’t have one leave it blank – typing the word none or a 0 will cause an error – Place for registration of subsidiaries at this stage:  The Account Manager will also have the ability to enter this information – so you may want to wait  Determine whether they really need to be registered under the RRE Entity – if they are not – there is no need to register them at all  To register a subsidiary – note – that each subsidiary must have its own distinct TIN or the system will not accept the registration – CMS does not allow for the registration of an off-shore entity

21 Marsh | ASHRM Registration Tips – (Con’t)  Account Manager Step – Be sure that you know who your reporting agent will be and have contact information for that entity and its Tax ID Number as well – Be sure to have a specific contact for the reporting agent – Be sure to have a specific contact for the technology contact – Be sure to know the upload method to be used for reporting to CMS (your reporting agent should have this information) – Be sure you know whether your reporting agent will use the COBC HIPAA compliant wrapper software for the reporting (your reporting agent should have this information)

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23 Marsh | ASHRM Report When to Report  Quarterly Reports (Required) – Reports must be submitted every quarter for every RRE ID# for your program – Formal reporting will be required as of April 1,  Monthly Queries (Not Required – sort of)

24 Marsh | ASHRM Report What to Report  Any settlement, judgments, awards or other payments; – Includes the assumption of an on-going responsibility for payment of medicals (ORM).  Made to or on behalf of a Medicare Beneficiary; – People age 65 or older; – People under age of 65 with certain disabilities; and – People of all ages with End-Stage Renal Disease.  For any claim in which medicals are claimed and/or released. – If medicals are claimed and/or released, the settlement judgment, award or other payment must be reported regardless of any allocation made by the parties or a determination by the court. (CMS NGHP User Guidelines, pp. 10, 49, 55-57)

25 Marsh | ASHRM Report Single Payments  In the case where there is a single indemnity payment made in satisfaction of a claim or suit to a Medicare Beneficiary in which medicals were claimed and/or resolved, the indemnity payment must be reported to CMS in the quarterly upload file. (CMS NGHP User Guidelines, pp. 45; 50)  Because there is a single indemnity payment obligation (even if it is a structured settlement), the resolution of the claim would result in a single report made to CMS after the indemnity payment has been made. (CMS NGHP User Guidelines, p. 50)

26 Marsh | ASHRM Report On-Going Medicals (ORM)  In those situations where the RRE agrees to pay medical bills for additional or on-going treatment, as part of the resolution of the claim, CMS requires an initial report to inform CMS that the obligation to make those payments has been accepted by the RRE. (CMS NGHP User Guidelines, p. 50)  Once the obligation to make those payments ends, an update to the original file is sent to CMS, informing them of the total amount paid and the date when the obligation ceased. If there were additional indemnity dollars paid to settle the case, they are included in the updated report to CMS. (CMS NGHP User Guidelines, p. 50)

27 Marsh | ASHRM Report How to Report  Fields to be reported – Over 131 fields of information – Vast majority are required – Some seek information which may or may not be collected in the claims process  File Format  Uploads and Downloads to and from CMS

28 Marsh | ASHRM Report Errors in Submissions  CMS required fields not in file upload – Rejected – CMS response report  Error Codes  Late File Submissions – Report of settlement – CMS Response File  Compliance Flags

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30 Marsh | ASHRM Copyright 2009 Marsh Inc. All rights reserved. ASHRM is pleased to offer this audio conference as an educational service to its members. Any opinions expressed during this audio conference are the opinions of the speakers and are not opinions endorsed by ASHRM. ASHRM does not endorse any service/products that may be referenced or discussed during this audio conference. The information contained herein is based on sources we believe reliable, but we do not guarantee its accuracy. Marsh makes no representations or warranties, expressed or implied, concerning the application of policy wordings or of the financial condition or solvency of insurers or reinsurers. The information contained in this publication provides only a general overview of subjects covered, is not intended to be taken as advice regarding any individual situation, and should not be relied upon as such. Insureds should consult their insurance and legal advisors regarding specific coverage issues. All insurance coverage is subject to the terms, conditions, and exclusions of the applicable individual policies. Marsh cannot provide any assurance that insurance can be obtained for any particular client or for any particular risk. Statements concerning tax and/or legal matters should be understood to be general observations based solely on our experience as insurance brokers and risk consultants and should not be relied upon as tax and/or legal advice, which we are not authorized to provide. Insureds should consult their own qualified insurance, tax and/or legal advisors regarding specific coverage and other issues. The case studies included herein and discussed are for illustrative purposes only and should not be relied upon as governing your specific facts and circumstances. This document or any portion of the information it contains may not be copied or reproduced in any form without the permission of Marsh Inc., except that clients of any of the MMC companies need not obtain such permission when using this report for their internal purposes, as long as this page is included with all such copies or reproductions. Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).