Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) Overview Carolina RIMS September 2009

Presenters Steve Dalton, Chartis, VP - Home Office Workers Compensation P.O. Box 3115 Alpharetta, GA Work: (770) FAX: (866) Tom Thornton, Esq. Carr, Allison, Pugh, Howard, Oliver & Sisson 100 Vestavia Parkway Birmingham, AL Phone: FAX: Tom Blackwell, MSCC Gould & Lamb, LLC. Phone: (941) Ext Cell: (941) FAX: (941)

Steve Dalton, Chartis, VP - Home Office Workers Compensation P.O. Box 3115 Alpharetta, GA Work: (770) FAX: (866)

Background Effective in the second quarter of 2010, Medicare will for the first time require insurers and self insureds on all Liability, Workers’ Compensation and No Fault claims to report all settlements, judgments and awards completed after January 1, 2010 and all claims for which ongoing responsibility for medical (ORM) has been assumed or continues after July 1, 2009 involving a Medicare recipient to the Center for Medicare and Medicaid Services (CMS). Why? According to CMS… This reporting requirement is being implemented for the purpose of providing the federal government with a greater ability to enforce the provisions of the Medicare Secondary Payer (MSP) Act of 1980, which required that where there was a policy of insurance in place to cover medical treatment of the claimant, the insurance carrier would be the primary payer for that treatment in cases where the claimant was also eligible for Medicare.

Historical Perspective  Medicare Act passed in 1965 –Workers’ Compensation – primary payer  Medicare Secondary Payer Statute – 1980 –To protect the financial integrity of the Medicare Trust Fund –Added other Primary Payers  Liability  No-Fault  Self-insureds  GAO study released 1999 found $40-43 billion paid by Medicare during 7 year period that should have been paid by primary payers  Centers for Medicare & Medicaid Services (CMS) published first of series of memoranda providing direction to workers’ compensation for the protection of the interests of Medicare  Medicare & Medicaid SCHIP Extension Act of 2007 (MMSEA)

Responsible Reporting Entities (“RRE”)  An RRE is defined as the administrator or fiduciary of: –Liability insurance including self-insurance –No fault insurance –Workers’ compensation insurance  All RRE’s must register as a first step in compliance with MIR

Who is the RRE?  Generally, the entity paying benefits directly is the RRE  In guaranteed cost policies, the insurer is the RRE  In deductible policies, if the insurer is paying benefits directly and receives reimbursement from the insured within the deductible, the insurer is the RRE  In the case of a settlement, if the settlement exceeds the deductible and the insurer pays, the insurer is the RRE  Self-insureds without recourse to insurance are the RRE  Third party administrators are not the RRE for liability (including self-insurance), no-fault and workers’ compensation plans  If insured pays directly without recourse to existing insurance, the insured is the RRE  In Excess, Umbrella, Re-insurance, if the insurer begins paying benefits directly, the insurer is the RRE; if the insurer simply reimburses the insured, the insured is the RRE

Requirements and Registration SCHIP Mandatory Insurer Reporting By Tom Blackwell, Director of Strategic Services

Mandatory Insurer Reporting  Required on all NGHP (Liability, No-Fault, Self, WC) and GHP claims  Requires that primary payers check Medicare beneficiary status on ALL claims quarterly  Requires reporting of ALL claims involving Medicare beneficiaries quarterly  Requires reporting S/J/As on ALL claims involving Medicare beneficiaries  “Contested” cases exception  Applicable regardless of whether or not future medicals are closed

NGHP MIR Timeline  RRE Registration between 5/1/09 and 9/30/09 Only 1 reporting agent, TPA is not the RREOnly 1 reporting agent, TPA is not the RRE At time of registration, reporting date establishedAt time of registration, reporting date established  Testing of MQF from 7/1/09 to 12/31/09 Ensures Medicare verification process works properlyEnsures Medicare verification process works properly Requires seven (7) fields of dataRequires seven (7) fields of data  Testing of Production Files from 1/1/10 to 3/31/10 Ensures 180+ field feed properlyEnsures 180+ field feed properly Requires massive claims system additionsRequires massive claims system additions  1 st live report between 4/1/10 and 6/30/10 $1000/day/claim penalty begins$1000/day/claim penalty begins Retroactive reporting required from 7/1/09Retroactive reporting required from 7/1/09

RRE Registration Am I an RRE?Am I an RRE? Are you the funding source to the beneficiary?Are you the funding source to the beneficiary? How many RRE IDs do I need?How many RRE IDs do I need? How many entities or systems handle my claims?How many entities or systems handle my claims? How will they report the claims they handle?How will they report the claims they handle? Can these claims be sent to a central repository?Can these claims be sent to a central repository? How do I register with CMS?How do I register with CMS? Go to the web-site (authorized representative)Go to the web-site (authorized representative) Get your PIN & Credentials via mailGet your PIN & Credentials via mail Send to your Account Manager/Reporting AgentSend to your Account Manager/Reporting Agent Sign & Return your profile report from CMSSign & Return your profile report from CMS

MIR Requirements What Claims are Reportable?  Claims that involve Medicare Beneficiaries Doesn’t Include MedicaidDoesn’t Include Medicaid SCHIP enrollment not a factorSCHIP enrollment not a factor  Types of Claims Reportable Work Comp/Liability/No FaultWork Comp/Liability/No Fault BIBI Professional LiabilityProfessional Liability Malpractice (Med-Legal)Malpractice (Med-Legal) Medpay - PIPMedpay - PIP

MIR Requirements Look Back Dates  1/1/2009 Claims removed from Active/Current status prior is not reportedClaims removed from Active/Current status prior is not reported Will be reported upon next payment to claimantWill be reported upon next payment to claimant  7/1/2009 All currently open claims involving Medicare Claimants w/potential medicalAll currently open claims involving Medicare Claimants w/potential medical  7/1/2009 thru 1/1/2010 All Claims closed through settlement during this period must Claim but not TPOC amountAll Claims closed through settlement during this period must Claim but not TPOC amount

Medicare Eligibility Are You Closing or Limiting Future Medicals? Identify claimant’s Social Security & Medicare StatusIdentify claimant’s Social Security & Medicare Status Is this a Class I Beneficiary? - WC onlyIs this a Class I Beneficiary? - WC only Is this a Class II Beneficiary? - WC onlyIs this a Class II Beneficiary? - WC only Class III ? – WC & GLClass III ? – WC & GL Adequate Consideration in cases not meeting thresholdsAdequate Consideration in cases not meeting thresholds Liability/No Fault ClaimsLiability/No Fault Claims Medicare Claimants in settlements under $25,000Medicare Claimants in settlements under $25,000 Primary Payers are obligated under the lawPrimary Payers are obligated under the law No “Safe Harbors”No “Safe Harbors”

101 Riverfront Blvd, Suite 100 Bradenton, FL x Contact Information

Tom Thornton, Esq. Carr, Allison, Pugh, Howard, Oliver & Sisson 100 Vestavia Parkway Birmingham, AL Phone: FAX:

Concerns for the Industry:  Determination of Responsible Reporting Entity Status  Assess and assign exposure  Exam internal protocols and strategies for investigating and documenting claims  Exam protocols and strategies for evaluating, reserving and settlement of claims  Impact on litigation of cases

Responsible Reporting Entity  Definition  Registration –Timing –Elements

Assess and Assign Liability  Identify the players  Responsibility for fines  Renewals

Exam internal protocols and strategies for investigating and documenting claims  Is less more?  Determination of exposure  New claim handling protocols –Query function –Claimant is not a medicare recipient –Claimant is a medicare recipient

Exam protocols and strategies for evaluating, reserving and settlement of claims  Protection of Center for Medicare’s interest  Timing of settlements  Contingent agreements  Future exposure  Thresholds  Releases  Hardship application

Litigation  Burden upon defense bar  Burden upon plaintiff’s bar  Mediation/contingent agreements  Trial and judicial system

General Issues:  Recent extensions from Center for Medicare Services  Issues relating to worker’s compensation and ongoing responsibility for medical treatment  CMS alerts  Document retention protocols  Statute of Limitations for Federal Claims

Steve Dalton, Chartis, VP - Home Office Workers Compensation P.O. Box 3115 Alpharetta, GA Work: (770) FAX: (866) Tom Thornton, Esq. Carr, Allison, Pugh, Howard, Oliver & Sisson 100 Vestavia Parkway Birmingham, AL Phone: FAX: Tom Blackwell, MSCC Gould & Lamb, LLC. Phone: (941) Ext Cell: (941) FAX: (941) Contact Information