Mandatory Insurer Reporting: What Have We Learned So Far?

Since Mandatory Insurer Reporting (MIR) requirements came into existence, there have been a substantive number of changes as well as delays in the process as a whole.  As RREs and their reporting agents continue to navigate through what can be at times a cumbersome and complex reporting process, looking back to where we began and where we are now can seem like a daunting task.  However, taking a look back at what has happened over the past year can provide RREs and their reporting agents an opportunity to learn from past mistakes and inevitably improve and streamline their processes. 

What did we learn about MIR in 2011?

Do not Over-Report

PMSI believes that the most significant way to ease the pain of MIR is to avoid over-reporting. The benefits of reporting only what is required by CMS are that it:

  • Saves Time:  RREs are only collecting data on claims which must be reported
  • Reduces Reporting Errors: By reporting only clean claims which meet CMS validations, error rates are reduced
  • Reduces the possibility of interfering with a beneficiary’s Medicare benefits: Data issues can potentially interrupt Medicare benefits

In order to avoid the pitfalls of over-reporting, RREs should choose a reporting agent proven to have a clear cut process and a validation of claims according to published CMS guidelines.   Agents have taken different approaches to MIR and RREs must take steps to ensure that they understand exactly how their claims are being reported to CMS as this can have effects both within and outside of the MIR process. 

Some agents do not withhold claims outside of the published reporting requirement/ thresholds and others apply no validations whatsoever to the data they are submitting on behalf of the RRE and submit everything.   Essentially, the agents are providing unnecessary information which CMS does not require.

Data Scrubbing Ensures Incorrect Data is not Submitted to CMS 

Claims with missing or erroneous data fields are being transmitted to CMS to simply meet the deadline.  Unfortunately for the RRE, this is not a form of compliance.  CMS has confirmed that the sending of incomplete or erroneous data is the equivalent of not sending the data at all and does not increase the RRE’s level of compliance (please see PMSI’s recent blog entry on this issue for further details), yet many agents still have not built the proper validations into their reporting platform. Additionally, proper data scrubbing can lower the error rate of submissions. 

Ensure that you are Reporting Correct ICD-9 Codes

Another important aspect of this process involves reporting correct ICD-9 codes.  CMS has published various versions of acceptable and excluded ICD-9 codes specifically for MIR purposes.  Utilizing codes found on medical bills or relying on internet based ICD-9 search sites is not the ideal solution, as they may not match valid codes as defined by CMS for reporting purposes.   An ICD-9 look up tool, such as the tool created by PMSI for our clients, eliminates the unknown by limiting the codes to those accepted by CMS for MIR purposes.  If medical bills are not available, descriptions of diagnoses can be input and valid ICD-9 codes related to the condition(s) will be provided by the look up tool.  If billing forms are available, ICD-9 codes can be validated with the look up tool, ensuring acceptable codes are reported.  ICD-9 codes can be a significant source of confusion which will ultimately lead to errors if a valid code is not reported. 

Reporting the improper ICD-9 code can not only disrupt the reporting process, but can also interfere with a beneficiary’s Medicare coverage.  One ICD-9 code provided erroneously (unrelated to the injury) can cause Medicare to deny benefits to the beneficiary. PMSI, as well as the rest of the industry, have come across numerous examples of unfortunate Medicare beneficiaries being denied coverage.

If a beneficiary is experiencing difficulties with their Medicare benefits and have been advised it is a result of MIR, an RRE will need to have a clear picture of when the data was reported and what specific information (i.e. ICD-9 codes, TPOCs and ORM Termination date) was reported in order to determine how to assist the beneficiary.  PMSI addressed how to handle this issue in previous blog articles posted in August and November of 2011.

Moving Forward- Know Your Errors

PMSI’s results for 2011 depict an accuracy rating of approximately 99.89%. While this represents a good starting point, each error should be analyzed to fine tune the validation process to catch these issues before submitting data to CMS.  MIR, to quote an old saying, is not like playing horseshoes in that you do not get points for being close to hitting the mark.  Do you know your results for 2011?  If not, this may be something you want to obtain from your reporting agent, sooner than later.  It is better to understand error rates earlier in the game, and allow time for corrections to hit the mark, before CMS begins levying fines.  For more information on these topics, please visit PMSI’s article in the February 28, 2012 digital edition of Risk and Insurance

 

 

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