Transcript No Slide Title

VISIONS FOR THE FUTURE
Translating CMS Terminology for
your Claims Department
And
How to translate your children’s
text messages.
Medicare Secondary Payer
Mandatory Reporting
Imposed through Section 111 of the
Medicare, Medicaid, and SCHIP
Extension Act of 2007 (MMSEA)
Text Translations
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<3
</3
ILY
6Y
Protecting Medicare’s Interests
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Medicare is always secondary to
workers compensation insurance.
Future medical payments are
protected by Medicare Set-Aside
arrangements (2001).
Past payments are covered by this
new reporting so that Medicare can
recover any $$$ it paid that we should
have paid.
Conditional (Past) Payments made
by CMS
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Mandatory quarterly reporting of all
Medicare eligible claimants on the issues
of:
 ORM
 TPOCs
 Provides CMS the ability to query their files
and determine if they paid something that a
primary payer should have paid.
Conditional (Past) Payments made
by CMS
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Mandatory quarterly reporting of all
Medicare eligible claimants on the issues
of:
 Ongoing responsibility for medicals
(ORM)
 Total payment obligation to claimants
(TPOCs)
 Provides CMS the ability to query their files
and determine if they paid something that a
primary payer should have paid.
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411
511
AYS
AYT
MOS
LEMENO
Who must report?
RRE
Who must report?

The Responsible Reporting Entity for a claim
(including but not limited to):
 The insurance carrier where there is policy
coverage.
 The self-insured entity where the SI makes
payments directly to the claimant.
 The excess or reinsurance carrier where the
carrier makes payments directly to the claimant.
http://www.cms.gov/MandatoryInsRep/Downloads/
AlertWhoMustReportrev052610.pdf
Medicare Reporting Process
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Monthly query file to determine which
of our claimants are Medicare eligible.
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SSN or HICN: REQUIRED
First initial
Last name (6 characters)
DOB
Gender
Medicare Reporting Process
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Quarterly reporting of data on
Medicare eligible claimants
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Where ongoing responsibility for
medicals exists as of Jan 1, 2010
 On claims with settlements, judgments or
awards on/after October 1, 2010.
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LMBO
ROTFLMBO
Penalties for Non-Compliance
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Failure by a Responsible Reporting
Entity (RRE) to timely report a claim to
CMS has a penalty payment of $1000
per day per claim.
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Penalty collections have already been
allocated to the SCHIP program.
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NOYB
BFF
BFFNMW
CD9
CM
Challenges/Translations/Training
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Missing SSN or DOB
Date of accident for Occupational Diseases
Flagging TPOCs
Date of a TPOC
Settlement for solidary obligors
ICD-9 Coding (covered/alleged/released)
Denied Claims
RPO Claims
Missing SSN or DOBs
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At claim intake?
During the claim investigation.
Form recommended by CMS.
Documentation in the claims file.
http://www.cms.gov/MandatoryInsRep/Downloads/NG
HHICNSSNNGHPForm.pdf
Date of Accident for Occupational
Diseases
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Identifying OD claims and CT claims.
Date of last injurious exposure is the
date of accident in LA.
CMS: Date of first exposure
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After the date of Medicare eligibility
(which they won’t give us)
 Which could be with a different employer,
with no obligation to us, insured by
another carrier….
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OTP
DBEYR
DGT
EOD
RUMOF
Flagging TPOCs
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Payments to the claimant (but not all
payments)
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Settlements, judgment, award, or other
payment in addition to/apart from ORM.
 Structured settlement (total payout from
the annuity).
 Identify by Payment Codes?
TPOC Dates
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Defined in Field 100 of the Claim Input
File Detail Record.
Date payment obligation was signed if
court approval not required (not
necessarily the date of the check).
Date of court approval (on judgments
and consent judgments).
Do you have these dates in your
claims system?
TPOCs and Injuries Covered,
Alleged, or Released.
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New to User Guide 3.1
When claims are settled, ICD-9 coding
must cover any injuries covered,
alleged, or released.
Who tracks injuries alleged?
http://www.cms.gov/MandatoryInsRep/Downloads/NG
HPUserGuideV3.1.pdf
Settlement for Solidary Obligors
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Seriously? Really?
 Report the total amount of the settlement
paid by all parties .
 Even though you don’t have that payment
info in your system, and you are not issuing
those checks.
 In LA: Borrowing employer or
direct/statutory employer situation where
the settlement is partially funded by
another employer/insurer.
Text Translations
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GL2U
GTG
SUP
IDK
JK
ICD-9 Coding
For Claims with ORM
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One ICD-9 code, per covered body
part, up to 5. After 5, provide the
codes if they are available/applicable
(up to 19).
For 1/1/11 reporting, CMS will accept
Versions 27, 28, & 29.
Training…..
Conversions to ICD-10 and training
down the line.
ICD-9 Coding
For Claims with TPOCs
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One ICD-9 code, per covered, alleged,
or released body part, up to 5. After 5,
provide the codes if they are
available/applicable (up to 19).
Denied Claims
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ORM = No, right? Wrong.
Paying initial medical treatment
without an admission of liability.
Paying for an evaluation because your
statute requires it.
CMS will assume ORM from date of
accident until the ORM term date.
RPO (Reporting Purposes Only) or
Incident Only Claims
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Notice of the claim
 Carrier must have notice to query the file.
 The employer assumes responsibility as the
RRE if they are paying the claim and do not
report.
 Clmt (65) reports a knee injury to employer,
but does not seek medical care immediately.
Claim is submitted to carrier as an RPO. Is
this okay? The employee sees the doctor a
week later and files with Medicare. Is this
okay?
Text Translations
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BBL
BBIAM
L8R
L8RG8R
MTFBWU
Thank you!
Jill Breard
Director of RMS Operations
LWCC
(225) 231-0805
[email protected]