Medicare Secondary Payer (MSP) compliance has become an integral part of claims handling for both the injured plaintiff and his/her counsel, as well as the corporate defendant, its insurer, and its counsel. Litigants today must pay close attention and stay informed about plaintiff’s entitlement to Medicare, and whether Medicare makes any conditional payments related to the pending or settled claim. In addition, litigants today must know whether the plaintiff is enrolled in a Medicare Advantage Plan (MAP) or Prescription Drug Plan (PDP), and whether such plans make any conditional payments related to the pending or settled claim. Not knowing this will create havoc on your claim, your settlement, your practice, and your business.
As Required by Section 1893(h) of the Social Security Act, the United States Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Medicare Secondary Payer (MSP) Commercial Repayment Center (CRC) published its third annual report to Congress for FY 2016 in August 2017. Based on the Group Health Plan (GHP) and Non-Group Health Plan (NGHP) recovery work of the CRC, for FY 2016 (October 1, 2015 through September 30, 2016), CMS returned $88.35 million dollars to the Medicare Trust Funds.
We have heard various complaints that Responsible Reporting Entities are receiving Conditional Payment Notices with unrelated charges or that the Commercial Repayment Center (CRC) isn’t closing claims, but how much of this is CMS’ fault and how much blame rests on the claims adjuster and the RRE?
Recently, we celebrated a year since the Centers for Medicare & Medicaid Services (CMS) transitioned a portion of the Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). On October 5, 2015, the CRC assumed responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity, referred to as Applicable Plans (AP), as the identified debtor. Since then, CMS has been pursuing recovery directly from APs as the identified debtor when an applicable plan reports that it has ongoing responsibility for medicals (ORM) or otherwise notifies CMS of its primary payment responsibility, as the assumption is that the AP’s responsibility is not in dispute.
The Commercial Repayment Center (CRC) process was front and center at the November 17, 2016 CMS Town Hall Teleconference. After CMS updated listeners listened to information about the Medicare Secondary Payer Recovery Portal (MSPRP) and Social Security Number Removal Initiative (SSNRI), the CRC had the opportunity to present on lessons learned over the last year. Although it was clear that the process has improved regarding the accuracy of the conditional payments, the backlog remains an issue. The CRC discussed the perceived delays on lead development and explained that when they receive Mandatory Insurer Reporting (MIR), they must validate that all required information is in the report and missing or incorrect information is the primary cause for delay.
If your goal is 100% Medicare Compliance, then Reporting and Recovery need to go hand in hand as the Dynamic Duo of your claims process.
Flagship Services Group is one of the country’s premiere Medicare Secondary Payer (MSP) compliance services providers. It focuses on the property and casualty insurance industry, meaning its clientele are auto, no-fault, medical malpractice, products liability, general liability and workers compensation insurers. As a result, Flagship speaks to case adjusters, claims supervisors, regional managers, and insurance executives from around the country on a daily basis. More and more, these conversations are about Mandatory Insurer Reporting (MIR). And very specifically, more and more of these conversations are about correctly reporting Ongoing Responsibility for Medicals (ORM), and Total Payment Obligation to Claimant (TPOC).
As the No-Fault and Workers Compensation process with the Commercial Repayment Center (CRC) continues to unfold, many P&C Carriers are now receiving the next round of automated notifications from Medicare regarding outstanding conditional payments. For many, this is the first time they have seen an Intent to Refer letter.
You have probably heard the buzz about the changes Medicare has made with the Commercial Repayment Center (CRC) and No-Fault and Workers Compensation claims.
But what about Medicare LIABILITY claims?
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.