By George Hills | Aug 31, 2017

Our Minds Over Your Medicare Matters

When Medicare began in 1966, it was the primary payer for all claims except for those covered by Workers' Compensation, Federal Black Lung benefits, and Veteran's Administration (VA) benefits.
In 1980, Congress passed legislation that made Medicare the secondary payer to certain primary plans to shift costs from Medicare to the appropriate private sources of payment.
The Medicare Medicaid SCHIP Extension Act (MMSEA) was signed into law in Dec. 2007 and applies to both:
- Group Health Plans and Workers' Compensation, and
- Liability and No-Fault Auto plans (collectively referred to as non-GHP.)

There are several purposes for reporting:
- Discover unresolved Medicare liens (conditional payments) and seek immediate recovery.
- Cease making ongoing conditional payments in the future.
- Ensure that all settlements "adequately consider" (allocate) Medicare's interests as required by law.

Lack of compliance may result in up to $1,000 per day, per claim fine
It is estimated that $1.15b in fines could fund the State Children's Health Insurance Program (SCHIP)
Medicare beneficiaries, insurers, self-insured entities, recovery agents, and attorneys, are always responsible for understanding when there is coverage primary to Medicare, for notifying Medicare when applicable, and for paying appropriately.
For establishing appropriate Set-aside dollars in the settlement of a claim

Triggers for reporting include payment, settlement, judgment, and award.
MMSEA reporting requires reporting of claims involving Medicare Eligible individuals to CMS (Centers for Medicare and Medicaid Services) on a quarterly basis-
- ORM = Ongoing Responsibility of Medical- 1/1/2010
- Liability TPOC = Total Payment Obligation to Claimant- 10/1/2011
- No-Fault = Medpay- 1/1/2010 (is considered ORM)

ExamWorks represents the Client/Required Reporting Entity (RRE) as the designated reporting agent to report to CMS concerning Medicare beneficiaries.
ExamWorks is the vendor for all RRE's "Qualified Referrals" (those claims determined to require Medicare Set Aside (MSA) or a Claim Settlement Allocation (CSA).

GH is responsible for timely and accurate reporting of client-provided data to our Service Provider, ExamWorks, to meet all reporting requirements in accordance with MMSEA.
GH performs the necessary data gathering for reporting on behalf of RRE to ExamWorks.
GH performs necessary claims adjusting relating to the impact of potential Medicare Set-Aside MSA.

RRE's/GH must be able to determine whether an injured party is a Medicare beneficiary and gather the information required for Section 111 reporting. CMS allows RRE's and/or GH that are file submitters to submit a query to the BCRC to determine the Medicare status of the injured party prior to submitting claim information for Section 111 reporting.
On the query response record, the Benefits Coordination & Recovery Center (BCRC) will provide information on whether the individual has been identified as a Medicare beneficiary based upon the information submitted and if so, provide the Medicare HICN (and other updated information for the individual) found on the Medicare Beneficiary Database (MBD).
The reason for Medicare entitlement, and the dates of Medicare entitlement and enrollment (coverage under Medicare) are not returned in the query file response.