Your Adjusters are Struggling with Medicare Compliance

Posted by Kendell Gracey on Sep 10, 2014 1:43:00 PM

Since Medicare beneficiaries only make up between 15-18% of the U.S. population, your adjusters probably only see a Medicare claim once or twice a month at the most.  Most of them recognize terms like “Section 111 compliance” and know enough to realize a Medicare claim can be like a ticking time bomb from a regulatory standpoint, but with so little experience under their belt, “I have no idea where to begin” is a common thought.

Our experience has been that less than 5% of adjusters fully know how to properly identify a Medicare claim, accurately map out the route to compliant closure of the claim, and successfully follow that process all the way through to receipt of an official case closure letter (CCL) (link to new blog post) from Medicare.

That means that more than 95% of adjusters are likely to overlook claims that fall under Medicare reporting and recovery guidelines, fail to process them appropriately (or take forever doing so,) and are therefore leaving your organization exposed to potential non-compliance fines should an audit occur.

It's not their fault.

We're certainly not coming down on the adjusters here. 

To be fair, regulations surrounding Medicare-related personal injury claims reporting and recovery are constantly changing.  Keeping up with them is almost a full time job, and as noted above, they only account for less than 1 in 5 of the claims your adjusters see.

They're also very time-consuming.

The average personal injury claim involving a Medicare beneficiary can take upwards of an hour on the phone with a representative from the Benefits Coordination and Recovery Center (BCRC), and then between several months to years [Unknown A1] waiting on Medicare to process the claim to completion. 

So, with cycle times making up a large part of their performance review, and the relative infrequency with which they run into these claims, it's understandable that adjusters can be overwhelmed by the process.

There is a better way.

Here are a few best practices to help lower the stress on your adjusters while reducing financial exposure for your company:

  1. Start the process early – It's going to take time, so the earlier in the life of the claim your adjuster can get the process started, the better.
  2. Set expectations up front – All involved parties (claimant, claimant's counsel, providers, etc.) should be made aware up front of compliance requirements and how long it's expected to take to complete compliant processing.  This can cut down on ill-conceived settlements based on impatience or misunderstandings.
  3. Beware of “loaded terms” - Unlike many other claims, including “hold harmless” language in settlement agreements DOES NOT limit liability (link to new blog post) when it comes to Medicare claims.  Medicare can and will recover their due from any and all parties to the claim, regardless of this language, and their first target will always be the deepest pockets: the insurance company.

Another best practice that can summarily cover these three points and lead to 100% compliance on every Medicare claim is to allow Flagship Service Group to handle the  Medicare aspects of your claim.  Since this is all we do, all day, every day...

  • We're on top of current compliance requirements
  • We're able to process these claims faster than anyone else
  • We can provide 100% compliance – and help ensure a CCL is obtained for every claim.

To determine how much money Flagship Services Group can save you and assist you in achieving 100% compliance, take our free Medicare risk assessment today.

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