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Medicare Secondary Payer-What’s New? Commercial Repayment Center
Presenters: Katie A. Fox, MSCC, CMSP Executive VP of National Account Management
Ciara F. Koba, Esq. Associate, Burns White
Determining Medicare Status • Medicare Entitlement Age (65 or older) Social Security Disability Kidney disease Lou Gehrig’s disease
What is Medicare Secondary Payer? • Medicare Secondary Payer: when another entity other
than Medicare has the responsibility for paying for medical bills before Medicare.
• Established in 1980 legislation that made Medicare the secondary payer to primary plans Shifts costs from Medicare to appropriate private sources of
payment
• Three Compliance Responsibilities Created: Protect (or Consider) Medicare’s Interest Reimburse Medicare Conditional Payments Report Claims to Medicare Electronically
Medicare Secondary Payer Compliance Tracks
Rei
mbu
rse
Med
icar
e
Conditional Payments
Claimant Attorney Primary Plan
Not Shifting Responsibility to Medicare
Claimant Attorney Primary Plan*
Methods MSA Other
Prot
ect M
edic
are
(Fut
ure
Med
ical
)
MMSEA/MIR Section 111
Primary Plan Total Payment Obligation to Claimant (TPOC) Ongoing Responsibility for Medicals (ORM) R
epor
t to
Med
icar
e
The SMART Act: Where We Are Today • SMART Act was enacted on January 10, 2013.
• CMS had to enact and implement all but 1 major
provision of the SMART Act (the SOL provision was self-enabling).
• Most of the SMART Act is now implemented.
• Key remaining issue: Safe harbors against penalties for noncompliance with Section 111 Reporting Obligations
Statute of Limitations on MSP Recovery • If settled after July 10, 2013 and CMS is provided with
notice of the settlement, SOL is 3 years. • Discussion: Older demands may be barred by the SOL. Ensure
that the SOL has not passed. Ensure that notice is given by timely reporting
claims via Section 111. Could this SOL apply to MSAs as well? While SOL may bar a demand from Medicare,
subrogation rules still apply.
The SMART Act: Conditional Payment Appeals Process for Applicable Plans • New process for “applicable plans” to pursue conditional payment
appeals enacted April 28, 2015.
• Applicable plans are liability insurance (including self-insurance), no-fault insurance or a workers’ compensation law or plan.
• Four-level appeals process that mimics the prior appeals process that existed for beneficiaries
• WCMSAs Not Subject to Appeal
• Discussion: Will the appeals process take too long? Will applicable plans only utilize this process where the amount
contested is a large amount?
Introducing the New Players to NGHP MSP Recovery • Commercial Repayment Center - CRC Previously GHP, now includes NGHP with Ongoing
Responsibility for Medicals (ORM)
• Role after October 5th, 2015: As of October 5th, 2015 will identify and recover
conditional payments where the identified debtor was workers’ compensation, liability or no-fault insurance and the case was reported via Section 111. Where the identified debtor is the applicable plan, CRC
will be handling the recovery. The CRC will issue a CPN when notified of an ORM
report through MMSEA Section 111
Contractor Information Continued • BCRC Role after October 5th, 2015: Continue to handle all recovery cases initiated prior to
October 5th, 2015 Will continue to maintain responsibility for data collection
related to MMSEA Section 111 Reporting For new recovery cases post October 5th, 2015, BCRC
will only identify and recover conditional payments where the identified debtor is the beneficiary General liability claims, not brought to Medicare’s
attention via MMSEA Section 111 Reporting will still be handled at the BCRC Generally, the recovery process for liability claims will
remain the same as before and will remain with the BCRC.
ORM New Process • Report via MIR Data (from your claim system)
• CPN (Conditional Payment Notice) Issued – 30 Day
response period
• Dispute/Appeal ONE opportunity to dispute medical claims identified on CPN
before the Demand is issued. ONE opportunity to exercise new appeal process
• Demand Issued- 60 days and Intent to Refer Letter is
issued Debt is on the way to Treasury
Impact of ICD-10 on MSAs and Medicare Liens • As of October 1, 2015, all claims for services must be submitted
with ICD-10 codes • Practice tip – for all MSAs completed on or after October 1,
2015, utilize ICD-10 codes exclusively • Medicare Conditional Payment Summary Forms
For a period of time you will likely continue to see ICD-9 and ICD-10 codes on the conditional payment summary forms
Once all of the service dates on the form are on or after October 1, 2015, you should only see ICD-10 codes reflected
This should assist primary payers and beneficiaries with identifying unrelated payments that should not be on the payment summary form due to the greater specificity of the ICD-10 coding system
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Impact of ICD-10 on Section 111 Reporting • Any reports submitted prior to 10/1/2015 must use ICD-9-CM
diagnosis codes • Any reports submitted on or after 10/1/2015 must follow the new
requirements for coding per CMS’ User Guide and Memoranda Any claim input files and DDE add/update records submitted on or after
10/1/2015 with a CMS date of incident (DOI) on or after 10/1/2015 require the use of ICD-10-CM codes
ICD-9 or ICD-10 codes can be used for all add/update records submitted with a DOI prior to 10/1/2015 NOTE: Cannot submit ICD-9 & ICD-10 codes on the same record.
Not required to convert old ICD-9 codes that were submitted on previously accepted records even if you are updating those records.
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Impact of ICD-10 on Section 111 ORM Reporting
• Effective January 1, 2016, in situations where an insurer or workers’ compensation entity has reported to CMS that it has ORM for specific care or an injury, CMS’ claims processing contractors will use the information provided by the insurer or workers’ compensation entity to determine whether Medicare is able to make primary payment for those claims.
• Insurers and workers’ compensation entities that notify Medicare that they have ORM are strongly encouraged to report accurate ICD-9 or ICD-10 codes. Medicare’s claims processing contractors will use this information to pay accordingly.
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Impact of Inaccurate ICD-10 Reporting • How to find the correct codes
Examine hospital and medical bills but pull every code from the bills. Only pull the codes that are related to the claim.
Examine the medical records and claim information to determine the appropriate claimed and/or alleged injuries
Review the complaint, claim petition, release, etc. to obtain the correct injuries related to the claim
Provide training for claims staff on coding
• Be Careful! The ICD-9/10 codes that you report for Section 111 reporting will impact the beneficiary’s ability
to get Medicare coverage for those diagnoses in the future AND they will impact the Medicare conditional payment figures
Check Medicare’s list of approved codes for reporting
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Best Practices: ICD-10 Reporting • When assigning ORM and/or TPOC injury codes for Section 111
Mandatory Insurer Reporting (MIR), MSA injury codes related to the claim that will require future medical items and services, or while reviewing claims payment summaries received from the BCRC or CRC consider the following:
Don’t over report or under report. Even if the adjuster has paid the provider the charges billed under
no-fault/med pay or workers compensation, this does NOT mean that all injury ICD-10 codes have been accepted by the insurance carrier. The claim investigation, mechanism of injury, known pre-existing
or con-current conditions should play a role in deciding which ORM or TPOC injury ICD-10 codes should be assigned as being accepted.
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Questions & Discussion • [email protected] • [email protected]
