2015 Helios Settlement Solutions MSP Compliance Webinar Series: An Update on Mandatory Insurer Reporting

Rafael Gonzalez, Esq.
Vice President, Strategic Solutions, Settlement Solution, Helios

Medical InvoiceAt the top of our goals every year is to make sure we continue to serve our clients by providing several educational opportunities on all components of Medicare Secondary Payer compliance. This year, in addition to the blogs we have posted, presentations we have delivered, opinions we have written, and research articles we have published, we also presented three webinars on the latest MSP compliance issues. Over the next couple of weeks, we will review all three presentations, providing details about the substantive components of each offering.

On Wednesday July 29, 2015, from 1 to 2 pm, Helios Settlement Solutions hosted its first 2015 MSP Compliance Webinar, “An Update on Mandatory Insurer Reporting”. The webinar was 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 updated 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 discussed 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). They also updated attendees on the latest changes on who must report such information to CMS.

Frank and Rafael also reported on the latest ongoing responsibility for medical (ORM) changes. NGHP are responsible for reporting to CMS situations where primary payers have ongoing responsibility for medicals. They indicated that 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 also discussed changes in TPOCs. They indicated that NGHP are also responsible for reporting to CMS total payment obligation to claimant (TPOC). Since there is no de minimis 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 $1,000 as of October 1, 2014 or later.

Frank and Rafael also discussed 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 updated attendees on CMS new policy effective January 5, 2015, where a NGHP RREs may report the last five digits of the SSN, but still recommend reporting all nine 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 also discussed 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 at the time of their presentation, Frank and Rafael spent some time walking attendees through CMS policy pertaining to same specific to MIR. They informed 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 also made 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.

Last, Frank and Rafael also addressed 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.

We are so very appreciative for your trust and confidence in us. We are so very grateful for your reliance on us and for allowing us to continue to serve your MSP compliance needs. Be on the lookout for details on our 2016 Helios Settlement Solutions MSP Compliance Webinar Series. We will soon announce dates and times for CEU accredited quarterly presentations that will concentrate on legislative, regulatory, and legal updates to mandatory insurer reporting, conditional payment resolution, and set aside allocations, approval, and administration, as well as non-CEU quarterly offerings that will focus on outside the box, creative problem solving solutions to the MSP compliance issues you have asked us to address and assist you with. As always, we welcome your thoughts and ideas on how to better to serve you, including possible topics for discussion and presentation during our 2016 webinar series. Please contact us at 888.672.7674, or at contactus@helioscomp.com.

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About Rafael Gonzalez

As vice president of strategic solutions, Rafael Gonzalez serves as a thought leader on all aspects of Medicare and Medicaid compliance issues, including mandatory insurer reporting, conditional payments resolution, Medicare set aside allocations, CMS approval, and professional administration of Medicare set asides and special needs trusts. Prior to joining Helios, over the last 30 years, Rafael served as director of Medicare & Medicaid compliance and post settlement administration for Gould & Lamb in Bradenton, Florida. Before that, he served as chief executive officer for the Center for Lien Resolution, the Center for Medicare Set Aside Administration and the Center for Special Trusts Administration in Clearwater, Florida. Prior to that, he served as corporate counsel for FCCI Insurance, a workers’ compensation/property casualty insurance company in Sarasota, Florida. And before that, he practiced social security disability, workers’ compensation, longshore and personal injury law in Tampa, Florida. Rafael Gonzalez received his Bachelor of Science degree from the University of Florida and his Jurisprudence Doctorate degree from the Florida State University.

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