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.