2016 – The “Year of Medicare Compliance"

Posted by Brian Cox on Jan 5, 2016 4:34:50 PM

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According to the Chinese calendar, 2016 is the “Year of the Monkey.” But Medicare is one thing you shouldn’t monkey around with, so at Flagship, 2016 is the “Year of Compliance.”

Medicare rules, policies and processes are always changing. One thing that isn’t changing is that Medicare has put the monkey on your back to keep up-to-date and comply with all processes and policies.

A huge change Responsible Reporting Entities (RREs) are facing is the fact that the Commercial Repayment Center (CRC) is now proactively handling the investigation of Section 111 reports to identify claims where Medicare paid for services that need to be reimbursed.

We’ve reported on this development for months now because it’s such a dramatic change in the status quo for Medicare compliance.

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The CRC officially launched early in October, 2015, and we made as big a splash as we could to make sure everyone knew it was happening. But now it’s been over three months since the launch and most insurance carriers have not been flooded with Conditional Payment Notices (CPNs).

Was this all just a false alarm?

Absolutely not.

Don’t get lulled into a false sense of security! You need to remember that the CRC took on a huge project starting in October. If you were up-to-date with your Section 111 reporting, most of your claims would be recent. If the date of loss is recent on your reportable claims, it stands to reason that Medicare probably hasn’t received bills related to those claims. And they probably won’t receive and pay bills until the first quarter or even the second quarter.

We expect the first wave of CPNs to arrive in the mail early in 2016. And once they start coming, they won’t stop.

Please note, this is not some sort of scare tactic where we’re trying to spook you into spending money. This is a very real and serious threat to P&C insurers who insist on going about their business as if nothing’s changed.

Medicare compliance has always been fairly complicated, and with the inclusion of the CRC in the mix, the situation has become even more so. Just because you haven’t received CPNs yet, doesn’t mean you won’t.

You can expect them to arrive within the next few weeks.

So, if you haven’t done so, now is definitely the time to take a good look at your processes and make sure you’re compliant with the newest Medicare requirements heading into 2016.

What has remained the same?

For years now, RREs like P&C insurance companies have been responsible for querying all of their claims (usually on a monthly basis) to identify every claimant that is a Medicare beneficiary. Then, each quarter by their assigned date, they’ve been responsible for filing a report under the Section 111 guidelines notifying Medicare of all the beneficiaries for whom they’ve accepted Ongoing Responsibility for Medicals (ORM) or settled with.

That’s still the case: Section 111 regulations haven’t changed and RREs are still required to report quarterly as before.

This is a fairly simple process (when done correctly and routinely). As long as an RRE has a system in place for querying their claims that is free from errors and can be handled in a timely manner, they’re generally able to handle Section 111 reporting well.

However, the second half of the compliance equation has historically been more difficult for companies to routinely handle.

Reporting via Section 111 is NOT your only responsibility.

Many RREs mistakenly expected to be notified by Medicare if a lien existed based on their Section 111 reporting. That was never part of Medicare’s process.

Before October, the Medicare Reporting entity was NOT communicating with the Medicare Recovery entity.

Now, as of October 2015, the CRC will review Section 111 reports and proactively notify you of any outstanding liens for a particular beneficiary… but only on no-fault and workers comp claims.

What about liability claims? RRE’s don’t report liability claims to Medicare until they have settled. But you can’t go into settlement negotiations just assuming that there is no Medicare lien or even guessing at an amount. This creates a Catch-22 because without knowing whether or not there’s a Medicare lien and how much you’re going to be expected to reimburse them, how do you decide on an appropriate settlement amount? Ask yourself these questions:

  • What can you do to be compliant in 2016?
  • How do you handle CPNs and respond within Medicare’s mandated 30 day timeframe?
  • How can you protect yourself from unpleasant “surprise” liens?

The simplest and most effective way to guarantee 100% Medicare compliance and mitigate risk is the same as it’s always been: call Flagship Services Group. We can assist with the entire process, from querying your claims, to reporting, to negotiating Medicare liens, to filing the final closure documents, to ensuring compliance. Let us take the Medicare monkey off your back!

Even if you think you have an understanding of all of the new Medicare policies and procedures and you have a process to handle claims involving Medicare beneficiaries in place, we urge you to download the guide below to learn what you need to know about the CRC and the “new reality” facing RREs today.

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Topics: Compliance, CRC