Medicare, Medicaid and SCHIP Extension Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA)Act of 2007 (MMSEA)
OverviewOverview
Carolina RIMSCarolina RIMSSeptember 2009September 2009
PresentersPresentersSteve Dalton, Chartis, VP - Home Office Workers CompensationSteve Dalton, Chartis, VP - Home Office Workers CompensationP.O. Box 3115P.O. Box 3115Alpharetta, GA 30023Alpharetta, GA 30023Work: (770) 870-2350Work: (770) 870-2350FAX: (866) 281-1835FAX: (866) 281-1835E-mail: E-mail: [email protected]@chartisinsurance.com Tom Thornton, Esq.Tom Thornton, Esq.Carr, Allison, Pugh, Howard, Oliver & Sisson Carr, Allison, Pugh, Howard, Oliver & Sisson 100 Vestavia Parkway Birmingham, AL 35216100 Vestavia Parkway Birmingham, AL 35216Phone: 205-822-2006Phone: 205-822-2006FAX: 205-822-2057FAX: 205-822-2057E-mail: E-mail: [email protected]@carrallison.com Tom Blackwell, MSCCTom Blackwell, MSCCGould & Lamb, LLC.Gould & Lamb, LLC.Phone: (941) 798-2098 Ext. 1340Phone: (941) 798-2098 Ext. 1340Cell: (941)447-6814Cell: (941)447-6814FAX: (941) 798-3403FAX: (941) 798-3403E-mail: E-mail: [email protected]@gouldandlamb.com
Steve Dalton, Chartis, VP - Home Office Workers Steve Dalton, Chartis, VP - Home Office Workers CompensationCompensationP.O. Box 3115P.O. Box 3115
Alpharetta, GA 30023Alpharetta, GA 30023Work: (770) 870-2350Work: (770) 870-2350FAX: (866) 281-1835FAX: (866) 281-1835
E-mail: [email protected]: [email protected]
BackgroundBackground
Effective in the Effective in the second quarter of 2010second quarter of 2010, Medicare will , Medicare will for the first for the first time time require insurers and self insureds on all Liability, Workers’ require insurers and self insureds on all Liability, Workers’ Compensation and No Fault claims to report all settlements, Compensation and No Fault claims to report all settlements, judgments and awards completed after judgments and awards completed after January 1, 2010January 1, 2010 and all and all claims for which ongoing responsibility for medical claims for which ongoing responsibility for medical (ORM)(ORM) has been has been assumed or continues after assumed or continues after July 1, 2009July 1, 2009 involving a Medicare involving a Medicare recipient to the Center for Medicare and Medicaid Services (CMS).recipient to the Center for Medicare and Medicaid Services (CMS).
Why? According to CMS…Why? According to CMS…
This reporting requirement is being implemented for the purpose of This reporting requirement is being implemented for the purpose of providing the federal government with a greater ability to enforce the providing the federal government with a greater ability to enforce the provisions of the Medicare Secondary Payer (MSP) Act of 1980, provisions of the Medicare Secondary Payer (MSP) Act of 1980, which required that where there was a policy of insurance in place which required that where there was a policy of insurance in place to cover medical treatment of the claimant, the insurance carrier to cover medical treatment of the claimant, the insurance carrier would be the primary payer for that treatment in cases where the would be the primary payer for that treatment in cases where the claimant was also eligible for Medicare.claimant was also eligible for Medicare.
Historical PerspectiveHistorical Perspective Medicare Act passed in 1965Medicare Act passed in 1965
– Workers’ Compensation – primary payerWorkers’ Compensation – primary payer Medicare Secondary Payer Statute – 1980Medicare Secondary Payer Statute – 1980
– To protect the financial integrity of the Medicare Trust FundTo protect the financial integrity of the Medicare Trust Fund
– Added other Primary PayersAdded other Primary Payers Liability Liability No-FaultNo-Fault Self-insuredsSelf-insureds
GAO study released 1999 found $40-43 billion paid by Medicare during GAO study released 1999 found $40-43 billion paid by Medicare during 7 year period that should have been paid by primary payers7 year period that should have been paid by primary payers
Centers for Medicare & Medicaid Services (CMS) published first of Centers for Medicare & Medicaid Services (CMS) published first of series of memoranda providing direction to workers’ compensation for series of memoranda providing direction to workers’ compensation for the protection of the interests of Medicarethe protection of the interests of Medicare
Medicare & Medicaid SCHIP Extension Act of 2007 (MMSEA)Medicare & Medicaid SCHIP Extension Act of 2007 (MMSEA)
Responsible Reporting Entities (“RRE”)Responsible Reporting Entities (“RRE”)
An RRE is defined as the administrator or fiduciary An RRE is defined as the administrator or fiduciary of:of:– Liability insurance including self-insuranceLiability insurance including self-insurance– No fault insuranceNo fault insurance– Workers’ compensation insuranceWorkers’ compensation insurance
All RRE’s must register as a first step in All RRE’s must register as a first step in compliance with MIRcompliance with MIR
Who is the RRE?Who is the RRE? Generally, the entity paying benefits directly is the RREGenerally, the entity paying benefits directly is the RRE In guaranteed cost policies, the insurer is the RREIn guaranteed cost policies, the insurer is the RRE In deductible policies, if the insurer is paying benefits directly In deductible policies, if the insurer is paying benefits directly
and receives reimbursement from the insured within the and receives reimbursement from the insured within the deductible, the insurer is the RREdeductible, the insurer is the RRE
In the case of a settlement, if the settlement exceeds the In the case of a settlement, if the settlement exceeds the deductible and the insurer pays, the insurer is the RREdeductible and the insurer pays, the insurer is the RRE
Self-insureds without recourse to insurance are the RRESelf-insureds without recourse to insurance are the RRE Third party administrators are not the RRE for liability Third party administrators are not the RRE for liability
(including self-insurance), no-fault and workers’ compensation (including self-insurance), no-fault and workers’ compensation plansplans
If insured pays directly without recourse to existing insurance, If insured pays directly without recourse to existing insurance, the insured is the RREthe insured is the RRE
In Excess, Umbrella, Re-insurance, if the insurer begins In Excess, Umbrella, Re-insurance, if the insurer begins paying benefits directly, the insurer is the RRE; if the insurer paying benefits directly, the insurer is the RRE; if the insurer simply reimburses the insured, the insured is the RREsimply reimburses the insured, the insured is the RRE
Requirements and Requirements and RegistrationRegistration
SCHIP Mandatory Insurer SCHIP Mandatory Insurer ReportingReporting
Requirements and Requirements and RegistrationRegistration
SCHIP Mandatory Insurer SCHIP Mandatory Insurer ReportingReporting
By
Tom Blackwell, Director of Strategic Services
Mandatory Insurer Mandatory Insurer ReportingReporting
RequiredRequired on all NGHP (Liability, No-Fault, Self, on all NGHP (Liability, No-Fault, Self, WC) and GHP claimsWC) and GHP claims
RequiresRequires that primary payers check Medicare that primary payers check Medicare beneficiary status on ALL claims quarterlybeneficiary status on ALL claims quarterly
RequiresRequires reporting of ALL claims involving reporting of ALL claims involving Medicare beneficiaries quarterlyMedicare beneficiaries quarterly
RequiresRequires reporting S/J/As on ALL claims reporting S/J/As on ALL claims involving Medicare beneficiariesinvolving Medicare beneficiaries
““Contested” cases exception Contested” cases exception Applicable regardless of whether or not future Applicable regardless of whether or not future
medicals are closedmedicals are closed
NGHP MIR TimelineNGHP MIR Timeline RRE Registration between 5/1/09 and 9/30/09RRE Registration between 5/1/09 and 9/30/09
• Only 1 reporting agent, TPA is not the RREOnly 1 reporting agent, TPA is not the RRE• At time of registration, reporting date establishedAt time of registration, reporting date established
Testing of MQF from 7/1/09 to 12/31/09Testing of MQF from 7/1/09 to 12/31/09• Ensures Medicare verification process works properlyEnsures Medicare verification process works properly• Requires seven (7) fields of dataRequires seven (7) fields of data
Testing of Production Files from 1/1/10 to Testing of Production Files from 1/1/10 to 3/31/103/31/10• Ensures 180+ field feed properlyEnsures 180+ field feed properly• Requires massive claims system additionsRequires massive claims system additions
11stst live report between 4/1/10 and 6/30/10 live report between 4/1/10 and 6/30/10• $1000/day/claim penalty begins$1000/day/claim penalty begins• Retroactive reporting required from 7/1/09Retroactive reporting required from 7/1/09
RRE RegistrationRRE Registration
• Am I an RRE?Am I an RRE?• Are you the funding source to the beneficiary?Are you the funding source to the beneficiary?
• How many RRE IDs do I need?How many RRE IDs do I need?• How many entities or systems handle my claims?How many entities or systems handle my claims?• How will they report the claims they handle?How will they report the claims they handle?• Can these claims be sent to a central repository?Can these claims be sent to a central repository?
• How do I register with CMS?How do I register with CMS?• Go to the web-site (authorized representative)Go to the web-site (authorized representative)• Get your PIN & Credentials via mailGet your PIN & Credentials via mail• Send to your Account Manager/Reporting AgentSend to your Account Manager/Reporting Agent• Sign & Return your profile report from CMSSign & Return your profile report from CMS
MIR RequirementsMIR Requirements
What Claims are Reportable?What Claims are Reportable? Claims that involve Medicare Claims that involve Medicare
BeneficiariesBeneficiaries• Doesn’t Include MedicaidDoesn’t Include Medicaid• SCHIP enrollment not a factorSCHIP enrollment not a factor
Types of Claims ReportableTypes of Claims Reportable• Work Comp/Liability/No Fault Work Comp/Liability/No Fault • BI BI • Professional Liability Professional Liability • Malpractice (Med-Legal) Malpractice (Med-Legal) • Medpay - PIPMedpay - PIP
MIR RequirementsMIR Requirements
Look Back DatesLook Back Dates
1/1/20091/1/2009• Claims removed from Active/Current status Claims removed from Active/Current status
prior is not reportedprior is not reported• Will be reported upon next payment to Will be reported upon next payment to
claimantclaimant
7/1/20097/1/2009• All currently open claims involving Medicare All currently open claims involving Medicare
Claimants w/potential medicalClaimants w/potential medical
7/1/2009 thru 1/1/20107/1/2009 thru 1/1/2010• All Claims closed through settlement during All Claims closed through settlement during
this period must Claim but not TPOC amountthis period must Claim but not TPOC amount
Medicare EligibilityMedicare EligibilityAre You Closing or Limiting Future Are You Closing or Limiting Future
Medicals?Medicals?
• Identify claimant’s Social Security & Medicare Identify claimant’s Social Security & Medicare StatusStatus• Is this a Class I BeneficiaryIs this a Class I Beneficiary? - WC only? - WC only
• Is this a Class II BeneficiaryIs this a Class II Beneficiary? - WC only? - WC only
• Class IIIClass III ? – WC & GL ? – WC & GL
• Adequate Consideration in cases not meeting Adequate Consideration in cases not meeting thresholdsthresholds
• Liability/No Fault ClaimsLiability/No Fault Claims• Medicare Claimants in settlements under $25,000Medicare Claimants in settlements under $25,000
• Primary Payers are obligated under the lawPrimary Payers are obligated under the law
• No “Safe Harbors”No “Safe Harbors”
101 Riverfront Blvd, Suite 100101 Riverfront Blvd, Suite 100Bradenton, FL 34205Bradenton, FL 34205866-672-3453 x 1340866-672-3453 x 1340
[email protected]@gouldandlamb.comwww.gouldandlamb.comwww.gouldandlamb.com
Contact InformationContact Information
Tom Thornton, Esq.Tom Thornton, Esq.
Carr, Allison, Pugh, Howard, Oliver & Sisson Carr, Allison, Pugh, Howard, Oliver & Sisson
100 Vestavia Parkway Birmingham, AL 35216100 Vestavia Parkway Birmingham, AL 35216
Phone: 205-822-2006Phone: 205-822-2006
FAX: 205-822-2057FAX: 205-822-2057
E-mail: [email protected]: [email protected]
Concerns for the Industry:Concerns for the Industry: Determination of Responsible Reporting Determination of Responsible Reporting
Entity StatusEntity Status Assess and assign exposureAssess and assign exposure Exam internal protocols and strategies for Exam internal protocols and strategies for
investigating and documenting claimsinvestigating and documenting claims Exam protocols and strategies for Exam protocols and strategies for
evaluating, reserving and settlement of evaluating, reserving and settlement of claimsclaims
Impact on litigation of casesImpact on litigation of cases
Responsible Reporting Entity Responsible Reporting Entity Definition Definition RegistrationRegistration
– TimingTiming– ElementsElements
Assess and Assign LiabilityAssess and Assign Liability Identify the playersIdentify the players Responsibility for finesResponsibility for fines Renewals Renewals
Exam internal protocols and strategies for Exam internal protocols and strategies for investigating and documenting claimsinvestigating and documenting claims
Is less more?Is less more? Determination of exposureDetermination of exposure New claim handling protocolsNew claim handling protocols
– Query functionQuery function– Claimant is not a medicare recipientClaimant is not a medicare recipient– Claimant is a medicare recipient Claimant is a medicare recipient
Exam protocols and strategies for evaluating, Exam protocols and strategies for evaluating, reserving and settlement of claimsreserving and settlement of claims
Protection of Center for Medicare’s Protection of Center for Medicare’s interestinterest
Timing of settlementsTiming of settlements Contingent agreementsContingent agreements Future exposureFuture exposure Thresholds Thresholds ReleasesReleases Hardship applicationHardship application
LitigationLitigation Burden upon defense barBurden upon defense bar Burden upon plaintiff’s barBurden upon plaintiff’s bar Mediation/contingent agreementsMediation/contingent agreements Trial and judicial systemTrial and judicial system
General Issues:General Issues: Recent extensions from Center for Medicare Recent extensions from Center for Medicare
ServicesServices Issues relating to worker’s compensation Issues relating to worker’s compensation
and ongoing responsibility for medical and ongoing responsibility for medical treatment treatment
CMS alertsCMS alerts Document retention protocolsDocument retention protocols Statute of Limitations for Federal ClaimsStatute of Limitations for Federal Claims
Steve Dalton, Chartis, VP - Home Office Workers CompensationSteve Dalton, Chartis, VP - Home Office Workers CompensationP.O. Box 3115P.O. Box 3115Alpharetta, GA 30023Alpharetta, GA 30023Work: (770) 870-2350Work: (770) 870-2350FAX: (866) 281-1835FAX: (866) 281-1835E-mail: [email protected]: [email protected] Tom Thornton, Esq.Tom Thornton, Esq.Carr, Allison, Pugh, Howard, Oliver & Sisson Carr, Allison, Pugh, Howard, Oliver & Sisson 100 Vestavia Parkway Birmingham, AL 35216100 Vestavia Parkway Birmingham, AL 35216Phone: 205-822-2006Phone: 205-822-2006FAX: 205-822-2057FAX: 205-822-2057E-mail: [email protected]: [email protected] Tom Blackwell, MSCCTom Blackwell, MSCCGould & Lamb, LLC.Gould & Lamb, LLC.Phone: (941) 798-2098 Ext. 1340Phone: (941) 798-2098 Ext. 1340Cell: (941)447-6814Cell: (941)447-6814FAX: (941) 798-3403FAX: (941) 798-3403E-mail: [email protected]: [email protected]
Contact InformationContact Information
