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Mrc White Paper Mmsea Section 111
1. Protecting Medicare’s Interest through MMSEA: A Practical Guide for Responsible Reporting Entities A Medical Research Consultants White Paper September 2009
2. Introduction The passage of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) brings with it a new host of acronyms, burdensome reporting requirements, and the potential for large fines. MMSEA eventually will change the way all liability settlements are conducted.
3. History In order to understand the intent of MMSEA, we must first review the original Medicare Secondary Payer Statute (MSP) enacted in 1980. Medicare pays for health care for Americans over 65 years of age and those with certain disabilities. Prior to December 5, 1980, Medicare was the primary payer for all beneficiaries, even if a negligent third party was responsible for the related medical expenses. With the passage of the MSP provisions, Medicare became secondary to liability, no-fault, worker compensation and, in some cases, group health insurance. Prior to MMSEA, plaintiff counsel already had a duty to verify and resolve any conditional payments made by Medicare. MMSEA essentially places a new layer of reporting and potential penalties on payers (RREs) to ensure that Medicare’s interest is protected on all settlements. www.mrchouston.com
4. The role of and Section 111 MMSEA www.mrchouston.com
5. Key Dates RRE Registration Deadline: September 30, 2009 Testing: January 1, 2010- March 31, 2010 Live File Submission: April-June 2010 www.mrchouston.com
6. Step One: How to Register as an RRE www.mrchouston.com
7. Step Two: The Query Process Reporting claims data www.mrchouston.com
8. Step Two: The Query Process Verification of claimant status www.mrchouston.com
9. Step Two: The Query Process Data points www.mrchouston.com
10. Step Two: The Query Process Understanding reporting challenges www.mrchouston.com
14. Review of the lien resolution process (1) Once it is verified that a claimant is a Medicare beneficiary, a new case is entered by contacting the Coordinator of Benefits (COB). The COB enters the claim data and assigns the case to the Medicare Secondary Payer Recovery Contractor (MSPRC). This process should take 7-10 business days, but will likely take longer. The MSPRC assigns the file to a case manager. The case manager will request additional information about the injury and third party tortfeasor, along with a HIPAA authorization. www.mrchouston.com
15. Review of the lien resolution process (2) The MSPRC then must canvass all other Medicare contractors to locate any bills that may have been paid on the beneficiary. This process is likely to take at least 60-90 days. Once the MSPRC compiles all of the bills, they send a Conditional Payment Summary (CPS) which should include an itemized list of charges, including dates of service, amount billed and diagnostic codes. The CPS should then be reviewed to verify that each charge is related to the underlying settlement. This is accomplished by comparing each line item diagnostic code (ICD-9) to the diagnostic codes included in the injury allegation. www.mrchouston.com
16. Review of the lien resolution process (3) Any charges unrelated to the settlement should then be disputed with the MSPRC representative. Once settlement is reached, a demand letter is requested which includes the date of settlement, settlement amount and any procurement expenses (attorney fees, case expenses). MSPRC then sends out the final demand amount which must be paid within 60 days of receipt. www.mrchouston.com
17. Time is of the essence Given the proceeding process, the final resolution of Medicare’s interest may take at least six months if the process is not started prior to settlement. Success for both RRE’s and plaintiff attorneys lies in working together to identify Medicare beneficiaries, and starting the resolution as early as possible. It is critical that the ICD-9 codes reported to CMS match the injury allegations, so there is no discrepancy as to which charges are related. It is important for an RRE to obtain a copy of the most recent conditional payment summary prior to settlement either from the claimant or directly from MSPRC with an authorization signed by the claimant. In the case of an unrepresented claimant, the RRE will have even a greater incentive to participate early in the resolution process. If Medicare’s initial claim equals or exceeds the proposed settlement, all efforts must be made to evaluate, audit and compromise any liens if the settlement is to proceed. www.mrchouston.com
18. Conclusions MMSEA will change the entire claims process, from the way initial claims are entered, data is gathered and reported, and ultimately how claims are settled. An RRE must evaluate their claims systems, employee training, reporting capabilities and settlement procedures to determine the most efficient way to deal with this new reality. Medicare is intent on recouping its payments and the penalties and the associated liability for failing to protect Medicare on a settlement are too severe to ignore. www.mrchouston.com
19. Glossary of Terms Account Designee: Account Designees assist the Account Manager with the reporting process. They can be employees of the RRE or of an agent. There is no limit to the number of designees for any one RRE ID. Account Manager: Controls the administration of the account and manages the reporting process. The Account Manager can be an employee of the RRE or their agent. Account Representative: The Account Representative is ultimately accountable for an RRE’s Section 111 Reporting. The representative is typically an executive-level employee of the RRE and must have the legal authority to bind their organization. www.mrchouston.com Centers for Medicare and Medicaid Services (CMS): A federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards. Coordination of Benefits Contractor (COBC): Consolidates the activities that support the collection, management, and reporting of other insurance or workers’ compensation coverage for Medicare beneficiaries. Health Insurance Claim Number (HICN): unique identifier for claimant.
20. Glossary of Terms (continued) Medicare: A health insurance program for people age 65 or older, people under the age of 65 with certain disabilities, and people of all ages with End-Stage Renal Disease. Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA): Adds mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under Group Health Plans(GHP) or who receive settlements, judgments or awards from liability insurance, no-fault insurance and worker’s compensation. Medicare Secondary Payer (MSP): The term used when the Medicare program does not have primary payment responsibility (that is, another entity has the responsibility for paying before Medicare). Ongoing Responsibility for Medicals (ORM): Refers to an RRE’s responsibility to pay, on an ongoing basis, for the injured parties claims. Responsible Reporting Entity (RRE): Per CMS, An applicable plan, defined as the following laws, plan or other arrangements, including the fiduciary or administrator for such law, plan or arrangement(s): Liability Insurance, No-Fault Insurance and Worker’s Compensation Laws or Plans. Total Payment to Claimant (TPOC): refers to the dollar amount of a settlement, judgment, award, or other payment in addition to/apart from ORM. Tax Identification Number (TIN): IRS-assigned, Federal Tax Identification Number. www.mrchouston.com
21. Want to learn more? Contact: Randy Haynes Medical Research Consultants 713.528.6326 rhaynes@mrchouston.com www.mrchouston.com Founded in 1983, MRC offers a comprehensive support solution for legal, healthcare, and insurance professionals, including medical records analysis, record retrieval and management, lien research and resolution, coding audit and education, andcall center services. MRC has supported some of the largest mass torts on record, including toxic tort and products liability litigations, but also offers expertise in Pharmacovigilance, HCC Management, and individual personal injury cases. MRC is a certified woman-owned business, and is a preferred vendor for several major manufacturers and pharmaceutical companies, including Pfizer. MRC has been a Primary Service Provider for the DuPont Company since 2005.
