The reporting required by CMS to fulfill Mandatory Insurer Reporting (MIR) requirements went live on January 1, 2011. The processes to achieve full compliance are complex and require extensive technology, data scrubbing and timely submission for entities that must report claims. Many reporting entities have encountered difficulties, including significant issues with data validation—resulting in either not reporting eligible claims or unnecessarily reporting ineligible claims to CMS. These data issues can increase risk for payers, as data reported with errors can result in temporary suspension of reporting with CMS, increasing the risk of non-compliance penalties. Following is a sample of some of the challenges RREs face in meeting compliance and the potential results of these issues.
- Lack of a data validation process to ensure clean and accurate data prior to quarterly CMS reporting
- Data analysis or provision of timely reports for data cleansing prior to quarterly CMS reporting
Result: Failure to have visibility of claims errors may prevent the timely reporting of claims. Further, submitting data with an error rate higher than 20% will result in a threshold error which will cause the temporary suspension of report review and response by CMS.
Application of CMS requirements for workers’ compensation thresholds and liability guidelines
- Failure to capture workers’ compensation TPOC threshold
- Reporting all liability claims not just ORM liability, or using proper thresholds
Result: Reporting all claims will require resources to clean-up claims that are not currently or may not ever be reportable. Also, CMS will have a record of those claims reported early and may verify Medicare Secondary Payer (MSP) compliance on those cases.
Aggregation of data
- Multiple data providers using different systems to capture reportable data for the same RRE
Result: The use of outside vendors who cannot aggregate data can result in claims not being filed on time, data errors and additional fees by reporting vendor.
Sharing data with other data providers
- Some data providers have a limited ability or no ability to share data with other reporting agents
Result: Without a holistic view of the total claim population when multiple reporting agents are being utilized could interfere with the ability to drive MSP compliance.
Receiving reports to drive data clean-up and compliance
- Limits in the level of detail provided on reports may hinder the RRE from tracking full compliance with MMSEA Section 111 requirements on their claims.
Result: Inability to easily, adequately and proactively manage data providers to drive the data clean-up process and assure compliance.
Receiving ongoing technical support to ensure proper functionality of reporting application/process
- Additional costs incurred to ensure the reporting process runs smoothly and meets all client needs
Result: True cost of MIR program is unknown and client is unable to budget appropriately.
What issues have you encountered in the process?