Medicare Matters; We Make It Easy

History

• 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.)

Purpose

• 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.

Why Reporting Matters

• 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

Conditions

• 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 Role Reporting

• 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).

George Hills’ Role

•  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.

Client/RRE Role

• Client shall designate ExamWorks for all Qualified Referrals
• RRE may utilize other ExamWorks services related to MSP compliance.
• RRE shall keep their profile updated annually.

Querying for Medicare Eligibility

• 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.