Understanding the Understanding the Exposure Exposure SCHIP Mandatory SCHIP Mandatory

Insurer Reporting Insurer Reporting & MSP Compliance& MSP Compliance

Understanding the Understanding the Exposure Exposure SCHIP Mandatory SCHIP Mandatory

Insurer Reporting Insurer Reporting & MSP Compliance& MSP Compliance

Mandatory Insurer Reporting (MIR)

• RequiredRequired on all NGHP (Liability, No-Fault, on all NGHP (Liability, No-Fault, Self, WC) Self, WC)

• RequiresRequires that primary payers check that primary payers check Medicare beneficiary status on ALL claims Medicare beneficiary status on ALL claims quarterlyquarterly

• RequiresRequires reporting of ALL claims involving reporting of ALL claims involving Medicare beneficiaries quarterlyMedicare beneficiaries quarterly

• RequiresRequires reporting S/J/As on ALL claims reporting S/J/As on ALL claims involving Medicare beneficiariesinvolving Medicare beneficiaries

• ““Contested” cases exception Contested” cases exception • Applicable regardless of whether or not Applicable regardless of whether or not

future medicals are closedfuture medicals are closed

NGHP MIR Timeline• RRE Registration between 5/1/09 and 9/30/09RRE Registration between 5/1/09 and 9/30/09

• Only 1 reporting agent, TPA is not the RREOnly 1 reporting agent, TPA is not the RRE• At time of registration, reporting date establishedAt time of registration, reporting date established

• Testing of MQF from 7/1/09 to 12/31/09Testing of MQF from 7/1/09 to 12/31/09• Ensures Medicare verification process works Ensures Medicare verification process works

properlyproperly• Requires seven (7) fields of dataRequires seven (7) fields of data

• Testing of Production Files from 1/1/10 to Testing of Production Files from 1/1/10 to 3/31/103/31/10• Ensures 180+ field feed properlyEnsures 180+ field feed properly• Requires massive claims system additionsRequires massive claims system additions

• 11stst live report between 4/1/09 and 6/30/10 live report between 4/1/09 and 6/30/10• $1000/day/claim penalty begins$1000/day/claim penalty begins• Retroactive reporting required from 7/1/09Retroactive reporting required from 7/1/09

RRE Registration

Section 8 (pgs 22-26) NGHP User Guide

• Step 1:– Identify the Authorized Representative

• May not be an agent• Must be able to contract on behalf of the RRE

– Identify the Account Manager • May be an agent of the RRE• Controls the administration of the RRE’s account

– Identify COBSW Users• Manages the reporting process

RRE Registration

• Step 2: Determine Reporting Structure• How many RRE IDs are you planning on obtaining?• Multiple RRE IDs• 1 RRE ID = 1 Reporting Agent = 1 Quarterly Report• Multiple RRE IDs = 1 Reporting Agent = Multiple

Quarterly Reports

• Step 3: RRE Registration on the COBSW• PIN & RRE ID will be mailed to the Authorized

Representative

• Step 4: RRE Account Set up on the COBSW• May be done by the Account Manager

• Step 5: Authorized Representative Return Signed RRE Profile Report

ISAR MIR Workflow

• IIdentify : Check Medicare status on all dentify : Check Medicare status on all claims every monthclaims every month

•SSatisfy: Research/negotiate and resolve atisfy: Research/negotiate and resolve conditional payments prior to S/J/Aconditional payments prior to S/J/A

•AAllocate : Future medicals in the S/J/Allocate : Future medicals in the S/J/A

•RReport: On all Medicare eligible claims, eport: On all Medicare eligible claims, report the MIR data to CMSreport the MIR data to CMS

The OneSource Solution

• Solution for RRE should include:Solution for RRE should include:• Meet the full scope of SCHIP requirementsMeet the full scope of SCHIP requirements• Produce the proper MSP products:Produce the proper MSP products:

• In accordance with Gallagher Bassett protocolsIn accordance with Gallagher Bassett protocols• Medicare Set-Aside Allocation (MSA)Medicare Set-Aside Allocation (MSA)• Claims Settlement Allocation (CSA)Claims Settlement Allocation (CSA)• Conditional Payment Research (CPR)Conditional Payment Research (CPR)• Conditional Payment Negotiation (CPN) Conditional Payment Negotiation (CPN)

• Your cooperation is required to:Your cooperation is required to:• Avoid $1,000/claim per day penaltyAvoid $1,000/claim per day penalty• Reduce amounts paid for conditional paymentsReduce amounts paid for conditional payments• Protect against future liability (MSA/CSA)Protect against future liability (MSA/CSA)• Back-fill claims data to ensure MIR complianceBack-fill claims data to ensure MIR compliance

Selecting your Reporting Agent

• Data Integrity• Cost• Training• Transparency• Data Consolidation• Risk/Rewards

Program Structure and use of RRE ID’s

• Client RRE using a Reporting Agent• Client RRE using multiple

Reporting Agents• Client RRE self-administering

Post Registration Responsibilities

• Clients using Reporting Agents• Clients Self-Administering and

internally handling compliance with MMSEA 111.

Common misrepresentations of the Act

• Who is the RRE?• What coverage and policy holders

fall under Act?• Captives, Insurance Pools, State

Guarantee Funds?• Carriers in receivership• Exposure Claims/Occupational

Dease

Fines/Penalties/Data Integrity

• Technology Requirements needed for compliance?

• Penalty situations• When will fines be instituted?

101 Riverfront Blvd, Suite 100101 Riverfront Blvd, Suite 100Bradenton, FL 34205Bradenton, FL 34205866-672-3453 x 1340866-672-3453 x 1340

tom.blackwell@gouldandlamb.comdana.rose@gouldandlalmb.com

www.gouldandlamb.com

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