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Helios Settlement Solutions Webinar Series: An Update on Mandatory Insurer Reporting

By , July 27, 2015 2:32 pm

On Wednesday July 29, 2015, from 1 to 2 pm, Helios will host its latest Settlement Solutions Webinar, An Update on Mandatory Insurer Reporting. To sign up, please visit www.helioscomp.com/resources/education.

The webinar will be presented by Frank Fairchock, CMSP, Senior Manager of MedicareConnect at Helios and Rafael Gonzalez, Esq., Vice President of Strategic Solutions at Helios.

Frank and Rafael will be updating attendees on Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), which added mandatory insurer reporting (MIR) requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation plans (NGHP).

Frank and Rafael will be discussing several components of the MMSEA, including the Advanced Notice of Proposed Rule Making (ANPRM) on Civil Money Penalties published on December 11, 2013 by the Centers for Medicare and Medicaid services (CMS). The ANPRM solicited public comment on specific practices civil money penalties that could be imposed for failure to comply with MIR.

An organization that must report under Section 111 is referred to as a responsible reporting entity (RRE). In general terms, NGHP RREs include liability insurers, no-fault insurers, and workers’ compensation plans and insurers. RREs may also be organizations that are self-insured with respect to liability insurance, no-fault insurance, and workers’ compensation. Frank and Rafael will update attendees on the latest changes on who must report such information to CMS.

The purpose of Section 111 reporting is to enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. In other words, Section 111 NGHP reporting of applicable liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claim information helps CMS determine when other insurance coverage is primary to Medicare. Frank and Rafael will also report on the latest MIR changes.

NGHP are responsible for reporting to CMS situations where primary payers have ongoing responsibility for medicals (ORM). No-fault insurance ORM that existed or exists on or after January 1, 2010 must be reported. Liability insurance (including self-insurance) ORM that existed or exists on or after January 1, 2010 must be reported. And workers’ compensation ORM that existed or exists on or after January 1, 2010 must also be reported. Frank and Rafael will be discussing changes in these, including workers’ compensation ORM exclusions.

NGHP are also responsible for reporting to CMS total payment obligation to claimant (TPOC). Since there is no deminimis dollar threshold for reporting no-fault TPOCs, RREs are required to report all no-fault insurance TPOCs with dates of October 1, 2010 and subsequent. Regarding liability insurance (including self-insurance) TPOCs, RREs are required to report TPOC dates subsequent to October 1, 2011 with TPOC amounts greater than $1,000 as of October 1, 2014 or later. Regarding workers’ compensation TPOCs, RREs are also required to report TPOCs with dates of October 1, 2010 and subsequent, but only with TPOC amounts greater than $300 as of October 1, 2014 or later. Frank and Rafael will discuss changes that became effective the quarter beginning January 1, 2015.

In accordance with Section 204 of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act), CMS has modified the requirements related to the submission of HICNs and SSNs when NGHP RREs report settlements, judgments, awards, or other payments. As a result, Frank and Rafael will also update attendees on CMS new policy effective January 5, 2015, where a NGHP RREs may report the last five digits of the SSN.

Some NGHP RREs use a separate agent(s) to assist with tasks related to Medicare Secondary Payer (MSP) recovery demands or potential recovery demands. However, the Section 111 file layouts did not accommodate separate name and address fields for this purpose. As of July 13, 2015, RREs may submit recovery agent information as part of the Section 111 reporting. Frank and Rafael will also discuss how RREs may now submit their recovery agent information in new fields designated for this purpose.

With the transition from ICD-9-CM to ICD-10-CM Codes looming, Frank and Rafael will be spending some time walking attendees through CMS policy pertaining to same specific to MIR. They will inform listeners that for submissions beginning October 1, 2015, ICD-10-CM diagnosis codes will be required on all production Claim Input Files and Direct Data Entry (DDE) add and update records with a CMS DOI on or after October 1, 2015. They will also make it clear that either ICD-9-CM or ICD-10-CM diagnosis codes will be accepted on all add and update records with a CMS DOI prior to October 1, 2015. However, each record can only contain either all ICD-9-CM or all ICD-10-CM codes. RREs may not submit a combination of ICD-9-CM and ICD-10-CM diagnosis codes on one single record.

And if time permits, Frank and Rafael will also address exposure, ingestion, and implantation issues. CMS has consistently applied the MSP provision for liability insurance (including self- insurance) effective December 5, 1980. Therefore, when a case involves exposure to an environmental hazard or ingestion of a particular substance, Medicare focuses on the date of last exposure or ingestion for purposes of determining whether the exposure or ingestion occurred on or after December 5, 1980. Similarly, in cases involving ruptured implants that allegedly led to a toxic exposure, the exposure guidance or date of last exposure is used.  For non-ruptured implanted medical devices, Medicare focuses on the date the implant was removed.

In addition to this webinar on mandatory insurer reporting issues, Helios will also present a webinar on Wednesday September 16, 2015 on conditional payment (CP) resolution issues, including SMART Act implementation updates, the new CP portal process, and any changes resulting from switching from Benefits Coordination Recovery Center (BCRC) to Commercial Recovery Center (CRC) when CMS seeks reimbursement of conditional payments directly from the primary payer or applicable plan. Helios will also present a webinar on Wednesday November 4, 2015 on set aside allocations, including continuing changes in rated ages and therefore life expectancy, changes in medical care and services covered and not covered by Medicare, prescription drug changes and pricing issues, as well as updates on the workers compensation review contractor (WCRC) and its evolving review methodology and reconsideration process. You may sign up for these webinars by visiting www.helioscomp.com/resources/education.

CMS Announces NGHP Town Hall Teleconference for July 28, 2015

By , July 15, 2015 10:37 am

Post by Frank Fairchok MedicareConnect℠ Senior Manager

Post by
Frank Fairchok
MedicareConnect℠ Senior Manager


CMS has announced a Town Hall Teleconference on Tuesday, July 28, 2015 to provide comments about the upcoming transition of a portion of the Non-Group Health Plan Recovery Workload to the Commercial Repayment Center and to address both policy and technical questions for Section 111 reporting. The details to access the conference are as follows:

  • Date: July 28, 2015
  • Call-in time: 1:00 PM – 2:00 PM Eastern time.
  • Participation is by telephone only on call-in line: (800) 603-1774
  • Pass Code: Section 111

CMS encourages all participants to dial-in 20 minutes before the start of the call due to the high number of expected participants.

Questions will be answered live on the call and participants have the option of submitting the questions prior to the call to PL110-173SEC111-comments@cms.hhs.gov

Helios will participate in the teleconference to ensure our clients have access to the latest information from CMS for the topics discussed.

For more information, please contact Frank Fairchok, Senior Manager of MedicareConnect℠ at Frank.Fairchok@helioscomp.com.

NGHP User Guide 4.7 Released on July 13, 2015

By , July 14, 2015 9:42 am

Post by
Frank Fairchok
MedicareConnect℠ Senior Manager

CMS has released an updated User Guide with version number 4.7 on July 13, 2015. This update appears to incorporate alerts previously released only. CMS provides the summary of updates, along with the User Guide chapters impacted, as follows:

  • Change Request 32: Accept and process Recovery Agent information on Section 111 NGHP TIN Reference File (all chapters, predominantly Chapters III, IV, and V).
  • Change Request 15830: The URL for Section 111 was changed (all chapters).
  • Change Request 15931: To prevent false positives in partial SSN searches, the number of additional criteria needed to return a match is increased from three of four to all four (Chapter IV).
  • Change Request 15969: The response file naming convention was changed for NGHP files (Chapter IV).

Helios can provide a consolidated PDF file of all the updated chapters upon request. Please contact us at JustRegister@Helioscomp.com if you would like to receive this consolidated, searchable file.

For more information, please contact Frank Fairchok, Senior Manager of MedicareConnect℠, at Frank.Fairchok@helioscomp.com.

CMS Announces Switch on NGHP Conditional Payment Recovery from BCRC to CRC and Use of ICD-9 and ICD-10 to Determine Payment of Medical Bills

By , July 10, 2015 10:43 am
Article by Rafael Gonzalez, Esq. Vice President, Strategic Solutions HELIOS Settlement Solutions

Article by
Rafael Gonzalez, Esq.
Vice President, Strategic Solutions
HELIOS Settlement Solutions

On July 1, 2015, CMS published an announcement on its upcoming transition of Non-Group Health Plan recovery workload from the Benefits Coordination & Recovery Center to the Commercial Repayment Center.

As part of the continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, the Centers for Medicare & Medicaid Services (CMS) will be transitioning a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). CMS will also be working closely with its claims processing contractors to make sure that Medicare pays correctly in the MSP situations described below.

Effective October 2015, the CRC will assume responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity as the identified debtor.

The following should be noted regarding the planned workload transition:

  • The transition only includes those cases where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly.
  • Beneficiaries and their attorneys will continue to work with the BCRC where CMS is pursuing recovery from the beneficiary.
  • Webinars and town halls will be scheduled in the coming months to provide additional information.

For readers who are not familiar with Medicare’s Commercial Recovery Center, the CRC currently handles Group Health Plans (GHP) recoveries. Therefore, based on this announcement, it is anticipated that all NGHP recovery related activities, where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly, including refund checks, correspondence, and telephone inquiries will be handled by the CRC. This may include recovery demand letters, repayment of debt, administrative appeals request, and notice of intent to refer debt to the Department of Treasury letters.

We do not yet know whether there will be any changes to the current NGHP recovery process as a result of the CRC assuming responsibility for recovery of such conditional payments. As always, Helios Settlement Solutions will continue to track such changes and will continue to inform as to any procedural and administrative effects resulting from same.

The announcement also indicates that “effective January 1, 2016, CMS will add an additional limitation to Medicare claims payments where insurers or workers’ compensation entities have reported to CMS that they have Ongoing Responsibility for Medicals (ORM).”

The announcement explains that “in situations where an insurer or workers’ compensation entity has reported to CMS that it has ongoing responsibility for medicals (ORM) for specific care, CMS’ claims processing contractors will use the information provided by the insurer or workers’ compensation entity to determine whether Medicare is able to make payment for those claims.” As a result, “insurers and workers’ compensation entities that notify Medicare that they have ORM are strongly encouraged to report accurate ICD-9 or ICD-10 codes as Medicare’s claims processing contractors will use this information to pay accordingly.”

Although we have all known for quite some time that information provided to CMS via the Mandatory Insurer Reporting (MIR) process would be used to determine whether Medicare is the primary or secondary payer of any bill received by Medicare on any given claim, this announcement makes it clear that as of January 1, 2016, CMS will in fact start using the ICD-9 or ICD-10 reported by employer/carrier/TPA/agent to determine whether Medicare should pay or deny such bills.

As a result, with ICD-10 requirements starting October 1, 2015, now more than ever, every employer, carrier, third party administrator, or agent reporting such information to CMS needs to make sure that the ICD-9 or ICD-10 codes provided to CMS are accurate and comply with the applicable guidelines. Not doing so may result in Medicare paying for items it should not have paid for, or denying payments on items it should have paid. Either way, these errors and mistakes may become the source of potential private causes of action under the MSP, or liability and professional malpractice claims away from the MSP.

As an industry leader delivering what I believe to be the best platform for MIR compliance through MedicareConnect℠, Helios can assist RREs, TPAs and insurers ensure the proper use of ICD coding throughout all areas of MSP compliance. Coding the claim correctly means the best possible outcome once the claim is reported to CMS. As a result, Helios recommends the reporting process itself should be reliable and allow for sufficient guidance to ensure the claim is accepted by CMS without the issues of mixed coding or utilization of codes not acceptable by CMS for NGHP Section 111, including where plan type may prevent usage of specific codes. To learn more about Helios’ MedicareConnect℠, please contact us at 888.672.7674, or contactus@helioscomp.com, or www.helioscomp.com/settlement-solutions/medicareconnect-mir.

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