Medicare Reporting Information

November 24, 2009

Posted below are links to a number of reference materials that should be of value to your organization in complying with the federal Medicare Reporting of workers' compensation claims (where the worker is on Medicare.)

A provision in a bill passed by Congress in December 2007 requires general health care and liability insurers (including self-insurers for workers' compensation) were to report all of their Medicare eligible claims electronically, beginning July 1, 2009 on a test basis and October 1, 2009 on a production basis.  Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (which took effect January 1, 2008) requires all liability and workers' compensation insurance companies, self-insureds and others to review every open claim in their office and submit a 3 page, 45-part questionnaire form for every eligible file.  Originatlly, those forms were to be due at CMS (Center for Medicare & Medicaid) by July 1, 2009.  However, the TIMELINE has changed; you must have registered as a Required Reporting Entity (RRE) by September 30, 2009, and your production files are now to be submitted electronically by July 1, 2010.  As required by the MMSEA, ‘‘applicable plans,’’ must: (1) Determine whether a claimant is entitled to Medicare benefits; and, if so, (2) report the identity of such claimant and provide such other information as the Secretary may require to properly coordinate Medicare benefits with respect to such insurance arrangements in the form and manner (including frequency) as the Secretary may specify after the claim is resolved through a settlement, judgment, award or other payment (regardless of whether or not there is a determination or admission of liability). The penalty for failure to timely comply is a staggering $1,000 per day per claim! [NOTE: THESE DATES HAVE CHANGED!  READ THE UPDATED INFORMATION BELOW.]

These requirements apply to group health plans and liability insurers (including self-insurance for workers’ compensation.)  If your company is self-insured for group health and tort liability coverage, you will have to report those claims as well.

Many conference calls have been held (so far) by the Centers for Medicare & Medicaid Services (CMS) to answer the questions of those having to comply with the liability/workers’ compensation provisions. Transcripts from those teleconferences are helpful and can be found at https://www.cms.hhs.gov/MandatoryInsRep/07_NGHP_Transcripts.asp#TopOfPage.

Here are some website links at the Centers for Medicare & Medicaid Services website to help you in planning to comply with the new law:

INTRODUCTION TO MANDATORY MEDICARE REPORTING (revised)

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/IntroToSection111.pdf (original)

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/RevisedSection111022309.pdf (revised)

MEDICARE REPORTING OVERVIEW

https://www.cms.hhs.gov/MandatoryInsRep/

IMPLEMENTATION TIMELINE

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/MMSEATIMELINE.pdf (original)

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/RevisedImplementationTimeline050909.pdf (revised)

LIABILITY AND WORKERS' COMPENSATION USER'S GUIDE   NEW!!!

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPUserGuide2ndRev082009.pdf    NEW!!!

(includes registration information for Required Reporting Entities)

CMS ALERT DEFINING WHO IS A REQUIRED REPORTING ENTITY   NEW!!!

https://www.cms.hhs.gov/mandatoryInsRep/Downloads/NGHPRREDraftForPublicComment.pdf

CMS CLARIFICATION ON NON-MEDICAL PERIODIC PAYMENTS    NEW!!!

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/ALERTNGHPPeriodic%20Payment.pdf

CMS CLARIFICATION ON AUTHORIZED REPRESENTATIVES AND ACCOUNT MANAGER DETERMINATION    NEW!!!

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/AlertAuthRepAcctMgrDetermination.pdf

CMS DATA REPORTING "DO's AND DON'Ts"   NEW!!!

https://www.cms.hhs.gov/MandatoryInsRep/08_reporting_dos_and_donts.asp#TopOfPage

MARC COALITION USER GUIDE ABSTRACT

The MARC Coaltion's CMS User Guide Abstract

QUICK REGISTRATION GUIDE

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/QuickReferenceGuide050809.pdf

INTERIM RECORD LAYOUT FOR DATA COLLECTION & SUBMITTAL

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPInterim120508.pdf

(this replaces the Oct. 21, 2008 data collection layout)

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPInterfaceSpecVersion2.1.pdf

(includes the newest information on data changes to accommodate HIPPA)

TELECONFERENCE DATES FOR 2009 ANNOUNCED   NEW!!!

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPRevTeleconfDoc2009.pdf

*SUMMARIES FROM TELECONFERENCES*   UPDATED!!!

http://www.wsiassn.org/public/MedicareTeleconferenceSummaries08-09.html

MMSEA 111 COMPUTER BASED TRAINING    NEW!!!

http://www.cms.hhs.gov/MandatoryInsRep/05_Computer_Based_Training.asp#TopOfPage

(look to bottom of page for number to call)

Non-Group Health Training (i.e. - workers' compensation self-insurance)

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPCurriculum062609.pdf

AUTHORIZATION TO COLLECT SOCIAL SECURITY INFORMATION

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/CollectionofSSNsHICNsandEINsTINsALERT.pdf

FORM TO ASSIST IN COLLECTING REQUIRED INFORMATION    NEW!!!

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/HICNSSNBENEFORM.pdf

MEDICARE WEBSITE INFORMATION SPECIFIC TO LIABILITY

& WORKERS' COMPENSATION

CMS Web Page on Liability & Workers' Compensation Issues

ALERT FOR REPORTING MULTIPLE TOTAL

PAYMENT OBLIGATION TO THE CLAIMANT (TPOC) AMOUNTS

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPAlertTPOC.pdf

FEDERAL STATUTORY LANGUAGE

https://www.cms.gov/MandatoryInsRep/Downloads/StatutoryLanguage.pdf

SUPPORTING STATEMENT

https://www.cms.hhs.gov/MandatoryInsRep/Downloads/SupportingStatement082808.pdf

NEW!!!

IMPORTANT COMMENTS ON NEW REPORTING DATES

FROM UWC'S DOUG HOLMES

CMS Pushes Back Section 111 Registration and Reporting

In an Alert dated May 11, 2009, CMS announced that the registration period for non GHP Responsible Reporting Entities (RREs) has been extended from May 1, 2009 through September 30, 2009. This provides employers, insurers and federal and state agencies more time to determine RRE status and to arrange for registration.

CMS has not yet produced, but still expects to have model language in the near future that may be used by RREs to acquire SSNs or HICNs from individuals to be reported.

The bulk of the Alert is pasted below and the actual document may be accessed through the CMS web site at

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPV10UserGuide051109.pdf

Change/Delay in Testing Period for the Claim Input File and in the Start Date for the Live Production Submission of the Claim Input File:

All RREs must submit their first live production file no later than their assigned submission window for the April – June calendar quarter of 2010.

Testing for the submission of the Claim Input File will now take place from January 1, 2010, through March 31, 2010. Once testing is completed for an RRE ID, the system will set the RRE ID to a production status. However, testing may continue up until the first production Claim Input File is due. Test files will always continue to be accepted and processed after a production status has been attained.

RREs that complete testing before their assigned submission window for the January – March calendar quarter of 2010 may submit their first live production file in that calendar quarter during the file submission timeframe assigned to the RRE ID.

Instructions obsoleted by this ALERT: Version 1.0 of the User Guide reflects testing for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation RREs during the July – September quarter of 2009 with live production files scheduled for the October – December quarter of 2009. The supplemental ALERT issued dated March 20, 2009, extended the permissible testing period through December 31, 2009.

Start Date for Query Function Availability:

The Query Function will be available as of July 1, 2009, for those RREs who have completed registration and are in testing status (the RRE’s signed Profile Report has been received by CMS’ Coordination of Benefits Contractor (COBC)). Both test Query Input Files and production Query Input Files will be accepted and processed for an RRE ID in a testing status.

Although RREs have until September 30, 2009, to register, RREs cannot submit Query Input Files until they have completed registration and are in testing status for the applicable RRE ID(s).

Exception Regarding TPOC Reporting Dates and Reporting for Multiple TPOC Amounts Where the Reporting Threshold is a Consideration:

CMS has determined that the Section 111 reporting will not include the reporting of TPOC amounts with dates prior to January 1, 2010. Please disregard version 1.0 of the User Guide that reflects a requirement to report TPOC amounts dated on or after July 1, 2009.

Note: Dates associated with the Reporting of ORM have not changed.

Please refer to the supplemental ALERT dated March 20, 2009, regarding “Interim Reporting Thresholds.” Item 4.d. reads:

Where there are multiple TPOCs reported by the same RRE on the same record, the combined TPOC amounts must be considered in determining whether or not the reporting exception threshold is met. For TPOCs involving a deductible, where the RRE is responsible for reporting both any deductible and any amount above the deductible, the threshold applies to the total of these two figures.

Where a TPOC amount dated on or after January 1, 2010, falls below the threshold amount, the RRE must add all associated TPOC amounts dated on or after January 1, 2010, in determining if the reporting threshold is met. Any associated TPOC amount occurring prior to January 1, 2010 should not be considered when calculating the TPOC amount for purposes of the reporting threshold.

When the combined TPOC amounts meet the reporting threshold, the RRE shall report all TPOC amounts where the applicable TPOC date is on or after January 1, 2010. Timeliness will be determined based upon the applicable date for the TPOC which caused the threshold MMSEA111_NGHP_V1.0_UserGuideSupp_20090511

to be met. Each TPOC amount will be reported separately, the earliest as TPOC #1 in Fields 100 and 101 of the Claim Input File Detail Record, the next as TPOC #2 in Fields 90 and 91 of the Claim Input File Auxiliary Record, and so on.

Any subsequent additional TPOCs shall be reported, following the instructions for reporting additional TPOC amounts.

Although RREs are not required to report TPOCs where the applicable TPOC date is prior to January 1, 2010, a record will not be rejected based upon a TPOC date which is prior to January 1, 2010.

Summary of Changes to the Implementation Timeline:

May 1, 2009 --_September 30, 2009 Registration

July 1, 20009 Test and Production Query Input Files Accepted

January 1, 2010 Claim Input File Testing Begins

January 1, 2010 Production Claim Input Files Accepted

April 1, 2010 -- June 30, 2010 Initial Production Claim Input File Submissions

NEW!!!

WSIA & DEPARTMENT OF LABOR & INDUSTRIES' THOUGHTS 

WSIA Annual Conference Presentation on Medicare Reporting

Long ago WSIA felt that this was a very important issue for the members to hear about, and on which our local attorneys should be brought up to speed.  On Thursday, May 7, 2009 at WSIA's Annual Conference, attorney Thomas Thornton III spoke on the issue of Medicare Reporting under the SCHIP Act's Section 111 requirement.  The slides from his excellent presentation can be found HERE.

Department Issues Emails on Medicare Reporting

Without too much clarification, the Department of Labor & Industries issued an email on May 19, 2009 indicating that they would act as the Responsible Reporting Agency (RRE) for the State Fund, but not for self-insured employers.  Click HERE to read the content of the email clarifying their role relative to self-insurance.

Meeting With Department Clarifies Some Issues

There were a number of questions that self-insurers had related to how the Department of Labor & Industries was going to comply with the Medicare Reporting relative to the State Fund.  Here's what we know and can share with you at this time:

• Is the State Fund registered as an RRE (Required Reporting Entity) yet?  Not as of June 1, 2009.
• How is the State Fund interpreting claims with "ongoing responsibility for medical payments"?  The Department is interpreting this to mean all open claims with treatment orders, any reopened claim for additional medical treatment, and all pensions with treatment orders.  This will likely apply to all claims with prosthetics, including hearing aid claims.  They do not intend to do a cross-match with CMS's database for those medical only claims under $600 (which is allowed under the federal guidelines).  All of these claims are the ones they will "ping" against CMS's database to determine Medicare eligibility.
• Is the language on self-insured generated closure orders sufficient notice, as required under the federal guidelines?  Since the language on Department issued orders is not the same, will the language need to be changed on Department issued orders for self-insurers and the State Fund?  Yes, the Department believes the current language on self-insured issued closure orders is sufficient to draw the bright line on when medical treatment ends.  On their own orders, for both State Fund and those closure orders issued for self-insurers, the language will likely need to be changed to make it more clear.  This will help with compliance and consistency.
• Does the Department capture ICD9 codes?  Yes, but while Medicare provides a limited number of codes for submittal (19 codes), the Department will not limit the number of codes it uses in characterizing the conditions of the injured worker.  The Department will run a test to see how this will work with the State Fund system.
• What will the Department do with older claims that may or may not be in their computer system?  They will reactivate or reenter the claim data into the system, so that they will be able to match with Medicare's database.
• Has the Department received any legal advice on the scope of what RRE's are required to do?  Yes, though much of the legal advice has centered on the reporting of Social Security Numbers.  If sufficient information on the injured worker is available (name, address, age, etc.), it can be matched against the Medicare database and the Health Care Identification Number (HCIN) can be provided to the submitter in lieu of using/collecting Social Security Numbers.
• What happens when Medicare is making provisional treatment payments for non-curative treatment, and turns around and tries to charge the State Fund or self-insured employer for reimbursement of that treatment?  Contact CMS and ask if you have to pay for treatment that does not comport with state law.
• What happens on Third Party cases?  How do you take Medicare's interests into consideration, and how to you report it?  The Department did not provide an answer, but was requested to seek a legal opinion that they can share with the self-insured community.

Based on this initial meeting, we will continue to pursue answers to your questions with the Department and their response to this issue.  Please email us at dave.kaplan@wsiassn.org with any thoughts and questions you may have or want us to pursue.

Important Clarification on Required Reporting Entities

There's an important clarification regarding who does the submitting on behalf of Required Reporting Entities.  During the new registration step it’s absolutely critical that you provide information for your authorized representatives and not another user of the COB secure web site. Your authorized representative is defined in the various documentation that I’ve already noted as well as your user guide - reporting user guide. Typically this is an executive of the RRE. They must sign the profile report and agree to the data use agreement and ultimately will be held accountable for compliance of Section 111 reporting. It’s also critical that you note that this authorized representative for your RRE ID is never a user of the COB secure web site. Instead your users will be account managers and account designees.  Also during new registration the system will assign an EDI representative to be your main contact for technical issues.  In other words ... the authorized representative (CEO, President, Division Chief, etc. of your organization) cannot be the people who used the website to submit the data.  Make sure you have it listed correctly when you register!

RESOURCES

Third Party Data Submitter (Agent) - Piatt Consulting*

Crowe Paradis Press Release re Medicare Compliance Services*

CorVel Medicare Solutions*

MedAllocators, Inc.*   NEW!!!

*WSIA makes no claims or recommendations as to the potential providers listed here, but makes these names and information available in the event your Third Party Administrator (or you as a self-administered employer) are unable to act as your agent in submittal of the data required.  WSIA will add other data submittal providers as we are made aware of them.

OPPORTUNITIES TO LEARN MORE ABOUT THIS TOPIC

In addition to the Washington Self-Insurers Association presentation at our May 6-8, 2009 Annual Conference, there are a number of organizations that are holding meetings and putting out information where you can learn more about what's available to assist you in complying with the federal law.

SEDGWICK CMS MEDICARE UPDATE - February 4, 2009

GOULD & LAMB INDUSTRY NEWS BULLETIN - March 30, 2009

SEDGWICK CMS MEDICARE UPDATE - March 31, 2009

CORVEL MEDICARE MANDATORY REPORTING UPDATE - April 2009

NUQUEST BRIDGE POINTE CMS NEWSLETTER - April 2009

MEDALLOCATORS INC. CMS MEMO ON TIMELINE CHANGE - May 2009

CROWE PARADIS CMS NEWSLETTER (ERISA ISSUES) - May 2009

GAB ROBINS CMS MEMO ON TIMELINE CHANGE - May 2009

NUQUEST BRIDGE POINTE CMS NEWSLETTER - May 2009

CARR ALLISON CMS NEWSLETTER - June 2009

PIATT CONSULTING WEBINARS ON MEDICARE REPORTING

(there is a charge for these webinars)

MEDALLOCATORS INC. MEMO ON LAST TOWN HALL - August 2009

CARR ALLISON CMS NEWSLETTER - August 2009

MEDALLOCATORS INC. MEMO ON MEDICARE CHANGES - August 2009

CARR ALLISON CMS NEWSLETTER - September 2009   NEW!!!

CROWE PARADIS CMS NEWSLETTER - September 2009   NEW!!!

CROWE PARADIS CMS NEWSLETTER - October 2009  NEW!!!

CARR ALLISON CMS NEWSLETTER - November 2009   NEW!!!

 

*MEDICARE ADVOCACY RECOVERY COALTION (MARC)*

The Medicare Advocacy Recovery Coalition (MARC) seeks the removal of barriers contained within the Medicare Secondary Payer Statutes, Regulations & Rules that inhibit the prompt and fair administration of liability claims. The group supports rules that create:

• Transparency between CMS and Primary Plans with regard to conditional payment information

• Application of state law in the determination of the amount of conditional payment that may be collected

• Right of review of CMS decisions on conditional payments that may be owed

• Clear methods for the identification of who is “Medicare eligible” by a primary plan that provides for a
  safe harbor.

PURPOSE

• Ensure that Medicare beneficiaries receive coordinated and uninterrupted coverage for claims involving secondary payer issues

• Facilitate national level coordination, collaboration, and communication among the member organizations regarding Medicare reimbursement and recovery policy.

• Formulate policy recommendations to affect the member interests with respect to Medicare reimbursement and recovery procedures.

• Develop and implement legislative and regulatory strategy to enhance Medicare reimbursement and ensure that the secondary payer program works effectively, efficiently and economically.

   

MARC PRESS RELEASE ON CMS EXTENSION

OF REPORTING DEADLINES

MARC Coalition Welcomes CMS Extension of MSP Reporting Requirements and Clarification of Reporting Thresholds

 

BALTIMORE, March 24 /PRNewswire/ -- The Medicare Advocacy Recovery Coalition (MARC), a broad-based group advocating for Medicare Secondary Payor reform, today announced its appreciation for the federal extension of the Medicare Secondary Payer (MSP) reporting requirements for liability and other non-group health claims. By program memorandum, the Center for Medicare and Medicaid Services (CMS) announced that it was extending implementation of the MSP reporting process by three months, until January 1, 2010, and that it would impose an interim reporting threshold for liability claims of $5,000, below which claims need not be reported into the new system. The Agency’s actions respond to several of MARC’s major efforts over the past three months to educate CMS on the serious challenges of the data collection instrument for the liability industry, and the Coalition extends it thanks and appreciation to CMS for this most recent clarification.

 

“We have worked hard to build a cooperative and mutually respectful relationship with CMS,” said Katie Fox, co-chair of the MARC Coalition, “and the Agency’s actions today demonstrate not only that our message has gotten through, but that CMS has chosen to do the right thing. We appreciate the Agency’s action, and look forward to working closely with CMS as the MSP reporting program unfolds.” Similarly, Roy Franco, MARC Coalition co-chair noted: “We thank CMS for listening to us -- we appreciate that CMS has recognized the complexities involved in MSP reporting, and has allowed the industry the needed time to implement this new program.”

 

During the past three months, the MARC Coalition has been in close conversation with CMS staff and leadership, as well as with Congress, to ensure that the MSP reporting requirements can be implemented efficiently and sensibly. The Coalition is particularly thankful to those Members of Congress who worked to ensure that the MSP program succeeded.

 

More information about the CMS Alert can be found at:

http://www.cms.hhs.gov/MandatoryInsRep/Downloads/Allert_UserGuideSupp_NGHP.pdf

 

Risk managers and reporting entities interested in learning more about or in joining MARC can visit www.marccoalition.com or send an e-mail to info@marccoalition.com. 

 

Roy A. Franco

Director Risk Management Strategies

Safeway Inc.

4410 Rosewood Drive

Pleasanton, CA  94588

T:  (925) 226-5137

C:  (925) 216-5727

F:  (925) 226-5990

We will continue to add more educational opportunities and resources as we are made aware of them.  Check back here on a periodic basis.  Thank you!

Original page posted 25 February 2009

Updated 27 February 2009

Updated 17 March 2009

Updated 23 March 2009

Updated 25 March 2009

Updated 2 April 2009

Updated 9 April 2009

Updated 10 April 2009

Updated 19 June 2009

Updated 27 July 2009

Updated 29 August 2009

Updated 24 November 2009