The Department of Health and Human Services (HHSDepartment of Health and Human Services) Secretary Kathleen G. Sebelius announced on February 16, 2012 that HHSDepartment of Health and Human Services will be delaying the compliance deadline associated with the implementation of International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10International Classification of Diseases, 10th Edition). The proposed regulation was initially set to be effective October 1, 2011; however, in January of 2009 the implementation date was delayed to October 1, 2013. A new implementation date has not yet been confirmed; however the delay has provided a sense of relief to the industries who are impacted by the use of ICD-9International Classification of Diseases, 9th Revision codes.
The switch to ICD-10International Classification of Diseases, 10th Edition codes, when enacted, will not only have an impact on the medical provider community, but also on the insurance arena. As MMSEAMedicare Medicaid and SCHIP Extension Act Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
Reporting currently involves the usage of ICD-9International Classification of Diseases, 9th Revision codes to communicate diagnoses of Medicare beneficiaries to CMSCenters for Medicare and Medicaid Services, RREsResponsible Reporting Entities - payers subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA and reporting agents will be required to implement the necessary changes to their data submission processes to switch over to ICD-10International Classification of Diseases, 10th Edition. With the announcement of this delay, the industry should, hopefully, now have ample time to make the necessary internal changes to meet the deadline. The delay is certainly welcome by those who participate in the MMSEAMedicare Medicaid and SCHIP Extension Act Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
process.
According to the United States District Court for the Southern District of Texas, Medicare’s “gorilla body” could not be squeezed into Guadalupe Caldera’s (Caldera) “workers’ compensation overalls” via a private cause of action under the Medicare Secondary Payer Act (MSPMedicare Secondary Payer Act). This analogy was the court’s clever way of describing Caldera’s theory for his action seeking Declaratory Judgment that the Defendant, Insurance Company of the State of Pennsylvania (ICSP), was liable for the full amount Medicare paid on his behalf.1
Caldera injured his back in 1995 and ICSP originally paid some benefits pursuant to Texas law based upon his compensable injury and impairment rating. Additionally, Caldera applied for and received Social Security disability benefits in 1998. A few years later in 2002, ICSP filed a formal denial with the Texas Workers Compensation Commission denying Caldera additional medical benefits, asserting that the covered injury was previously resolved and that any new medical issues were not related. Although Caldera had been given notice and an opportunity to further pursue his claims with ICSP, he chose not to appeal and Medicare paid for his medical expenses including two back surgeries in 2005 and 2006 totaling $42, 637.41.
Continue reading 'Can “Medicare’s Gorilla Body be Squeezed into Workers’ Compensation Overalls”?'»
According to a WorkCompCentral article (subscription required) titled “Applicants Hope to Persuade WCABWorkers' Compensation Appeals Board on MSAsMedicare Set-Asides and Attorney Fees,” the issue of attorney fees as they relate to a case involving an MSAMedicare Set-Aside rose again at a recent conference in Rancho Mirage, California in January 2012. Attorneys Robert Rassp and Marguerite Sweeney both stated at the conference that they believe the California Workers’ Compensation Appeals Board (WCABWorkers' Compensation Appeals Board) used a flawed analysis in a 2010 opinion entitled Pratt v. Wells Fargo Bank.
In Pratt, the WCABWorkers' Compensation Appeals Board found that claimants’ attorneys should not include money in MSAsMedicare Set-Asides as a basis for calculating attorney fees. Pratt’s workers’ compensation matter involved her receiving an 82% permanent partial disability award and life pension. Pratt then sought to settle her right to future medical a year after receiving her initial award. When the future medicals were settled, she was to receive an MSAMedicare Set-Aside of $162,000. Her attorney requested attorney fees of $45,440, which was inclusive of the prior permanent partial disability and life pension awards as well as the new MSAMedicare Set-Aside money. The judge found that the attorney fees should only be $15,000, which was 5% of the new money excluding the $162,000 MSAMedicare Set-Aside. The WCABWorkers' Compensation Appeals Board affirmed this decision finding that the proper method for calculating attorney fees would be to not include funds for an MSAMedicare Set-Aside.
Continue reading 'Can Attorney Fees be Deducted from MSAsMedicare Set-Asides? The Debate Continues….'»
Historically, to initiate the conditional payment process, the COBCCoordination of Benefits Contractor would have to be placed on notice of the claim which would then result in the creation of a record in the Medicare database. This was accomplished by the injured party, attorney, RREResponsible Reporting Entity - payer subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA/TPAThird Party Administrator or their designated vendors communicating with the COBCCoordination of Benefits Contractor via telephone or in writing to ensure a record is on file for a beneficiary. This voluntary process did not consistently provide CMSCenters for Medicare and Medicaid Services with the necessary claims information for proper coordination of Medicare benefits. Typically, Medicare would not be aware of a carrier’s responsibility to pay medical treatment on a claim until settlement was contemplated and conditional payment verification was requested. Therefore, there was a high likelihood that Medicare could make conditional payments (possibly due to erroneous billing procedures on the part of the physician) when they were clearly a secondary payer. In an effort to tighten the coordination of benefit process and assure Medicare’s interest as a secondary payer are being protected, Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
of the MMSEAMedicare Medicaid and SCHIP Extension Act was enacted requiring RREsResponsible Reporting Entities - payers subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA to electronically report claims information to Medicare.
Now that Medicare has received claims data through Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting for over a year, on January 10, 2012 it was announced that self reporting of ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) will no longer be required. This information was provided in the form of an alert posted on the Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
webpage which confirmed that RREsResponsible Reporting Entities - payers subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA must report ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) through the Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting process as required rather than through a self report. Additionally, CMSCenters for Medicare and Medicaid Services confirmed that RREsResponsible Reporting Entities - payers subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA should no longer self-report exhaustion of benefits to the COBCCoordination of Benefits Contractor or the MSPRCMedicare Secondary Payer Recovery Contractor - responsible for verification of conditional payments, as this should also be handled through the Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting process. However, if the RREResponsible Reporting Entity - payer subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA needs to make an immediate report of ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) termination prior to their Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting date they can contact the COBCCoordination of Benefits Contractor and report ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) termination for a single claim as long as it was previously reported and accepted via Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
. It is important to remember that if an RREResponsible Reporting Entity - payer subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA chooses to contact the COBCCoordination of Benefits Contractor to make an immediate report of ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) termination they must still report this information through the Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting process as required.
Since RREsResponsible Reporting Entities - payers subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA do not report TPOCs until there is a settlement, judgment, award, or other payment (normally late in the claims process) self reporting may still be necessary. Claims data reported via Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
is communicated to the MSPRCMedicare Secondary Payer Recovery Contractor - responsible for verification of conditional payments after a settlement is reported which does not allow for verification of conditional payments prior to settlement. This is problematic for RREsResponsible Reporting Entities - payers subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA, TPAsThird Party Administrators, and claimant attorneys who are trying to properly consider Medicare’s interest during the settlement process. For claims involving TPOCs only (no ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case)), which is typical for liability claims and may involve denied workers’ compensation claims, it will be necessary to continue to self report claims to the COBCCoordination of Benefits Contractor in order to obtain conditional payment information prior to settlement. However, it is important to note that a self-report does not eliminate the RREResponsible Reporting Entity - payer subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA’s Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting obligations.
The changes noted in this alert are an indication of how CMSCenters for Medicare and Medicaid Services is working to improve the recovery process. These changes are a positive outcome of the Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting process which benefits those required to report, as well as CMSCenters for Medicare and Medicaid Services, and we hope that CMSCenters for Medicare and Medicaid Services will continue to make modifications to both the recovery process and Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
reporting process going forward.
Comments (0) 
Themocracy