Transcript Section 111 - Are You Ready for the New CMS Reporting

Section 111 - Are You Ready for the New
CMS Reporting Requirements?
Presented by:
Erin S. Zuiker
Smith Moore Leatherwood LLP
434 Fayetteville Street, Suite 2800
Raleigh, North Carolina 27601
T: (919) 755-8700
F: (919) 755-8800
Lisa K. Shortt
Smith Moore Leatherwood LLP
300 N. Greene Street, Suite 1400
Greensboro, North Carolina 17401
T: (336) 378-5200
F: (336) 378-5400
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Section 111 : New Reporting Rules
• Since 1980, The Centers for Medicare and Medicaid Services
(“CMS”) has had the right to be the Secondary Payer for any
medical expenses paid on behalf of a Medicare beneficiary.
• Through the MMSEA Section 111 Reporting Requirements, CMS is
exerting its right to always be the payer of last resort.
CMS
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Statutory Authority
• In 2007, Congress passed new legislation that added
teeth to the existing Medicare Secondary Payer (“MSP”)
law.
• The Medicare, Medicaid and SCHIP Extension Act of
2007 (“MMSEA”) amended the MSP provisions at 42
U.S.C. 1395y(b)
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Statutory Authority – MMSEA Section 111
• Section 111 of the MMSEA:
– Includes mandatory reporting requirements to ensure
Medicare’s status as a Secondary payer;
– Imposes new reporting requirements on all GHPs and
NGHPs; and
– Includes a penalty for non-compliance = $1,000 per
day, per claim.
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Section 111 : New Reporting Rules
• Mandatory Reporting Requirements:
– To accomplish its status as Secondary Payer, CMS
wants to know what entities are settling with Medicare
Beneficiaries.
– CMS now wants data, so that it can guarantee its
status as a Secondary Payer.
– Section 111 will enable CMS to ensure that it does not
make payments if another payer is responsible.
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Section 111 : New Reporting Rules
• Section 111 Reporting only applies to Medicare
Beneficiaries (it has no application to Medicaid).
• Under Section 111, if you or your organization pays the
medical expenses of a Medicare beneficiary, you must
report to CMS.
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Who is Impacted?
• Responsible Reporting Entities (“RRE”) are those
entities required to report data to CMS under Section 111
of the MMSEA
• CMS has categorized RREs into:
– Group Health Plans (“GHPs”); and
– Non-Group Health Plans (“NGHPs”).
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GHPs - 42 U.S.C. 1395y(b)(7)
• GHPs - 42 U.S.C. 1395y(b)(7)
– GHP - entity that in return for receipt of a premium,
assumes obligation to pay claims.
– Third Party Administrator (“TPA”) – entity that pays or
adjudicates claims on behalf of the GHP.
– For MMSEA Section 111, the GHP’s TPA is the RRE.
– Implementation began January 1, 2009.
– CMS estimates that 70% of all GHP MSP data is
already reported.
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NGHPs - 42 U.S.C. 1395y(b)(8)
• Focus of this presentation is on NGHPs
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NGHPs – The “applicable plan”
– The “applicable plan” includes:
• Liability insurance (including self-insurance);
• No-fault insurance; and
• Workers’ compensation.
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NGHPs
• Unlike GHPs, the TPA for NGHPs is not the RRE, “based
solely on its status as a TPA.”
• NGHPs may use an agent for reporting purposes,
though the liability for noncompliance remains with the
NGHP.
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What Must be Reported?
• Section 111 mandates that all payers will be responsible
for reporting any:
– Settlements;
– Judgments;
– Awards; or
– Other payments for any medical expenses…
That are paid on behalf of a Medicare
beneficiary.
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When To Report?
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When To Report?
• Section 111 requires a Quarterly Report to be submitted
to CMS.
• Each RRE was required to register between May 1, 2009
and September 30, 2009. Though registration remains
open.
– The RRE will be assigned an RRE ID.
– Each RRE ID will be assigned a Quarterly File
Submission Date.
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When To Report?
• Once registered, the RRE will begin a testing phase.
• The testing phase will run through March 31, 2010.
• Live data submissions will begin April 1, 2010.
© 2008 Smith Moore Leatherwood LLP. ALL RIGHTS RESERVED.
Responsible Reporting Entity (“RRE”)
•
Section 111 mandates that the RRE report specific information to CMS
beginning in 2010.
•
An RRE is the entity that actually pays the claim on behalf of a Medicare
eligible individual.
– Examples:
• An entity has 1st Dollar coverage for their liability insurance, the
Insurer is the RRE because the Insurer pays the claim in full.
• An entity has a Self-Insured Retention (“SIR”) amount of $500,000,
the Insured is the RRE for any monies paid to a Medicare
beneficiary out of the SIR amount.
• An entity does not have an insurance policy, but settles for $10,000
with an injured party who is a Medicare beneficiary, the entity paying
the claim is the RRE.
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RRE
• The RRE may contract with a TPA for their insurance
obligations, however the TPA is not the RRE “based
solely on its status as a TPA.”
• The Section 111 Reporting responsibility remains with
the RRE.
• The penalty of $1000/day/claim remains with the RRE.
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What Data?
• Data elements include:
–
Social security number;
–
Date of injury;
–
Plan information;
–
Settlement amounts; and
–
Legal representation information.
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How is Data Reported?
All submissions must be in an electronic format .
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Types of Settlements
• CMS has identified two Types of Settlements:
1. Total Payment Obligation to the Claimant (“TPOC”);
and
2. Ongoing Responsibility for Medicals (“ORM”).
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TPOC
• TPOC payments require only one reporting event:
– If at time of payment, the individual receiving payment
is a current Medicare beneficiary = Report
– If at time of payment, the individual receiving payment
is not a current Medicare beneficiary = Do Not Report
• That’s it!
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Reporting TPOCs
• All TPOCs as of January 1, 2010.
• TPOCs Interim Thresholds:
– 2010 – payments below $5000.00 exempt
– 2011 – payments below $2000.00 exempt
– 2012 – payments below $600.00 exempt
• But note, if multiple TPOCs are reported on the same
record or if a deductible is involved, the combined total is
used in determining the threshold.
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ORM
•
ORM payments require two reporting events:
1. If at time of payment, the individual receiving
payment is a current Medicare beneficiary = Report;
and
2. The second report is at the time the ORM payment
obligation terminates.
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ORM
• Note: If at the time of payment, the individual is NOT a
Medicare beneficiary, but later becomes a Medicare
beneficiary, the RRE is responsible for monitoring the
individual’s change in status and reporting the data to
CMS.
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Reporting ORMs
• ORMs incurred as of July 1, 2009 are reportable.
• No-fault and liability ORMs, including self-insurance,
have no de minimus dollar threshold .
• Workers’ Compensation ORMs – exempt through
12/31/2010, if meet ALL of the following:
– “Medicals only”’
– “Lost time” of no more than 7 calendar days
– All payment(s) has/have been made directly to the
medical provider
– Total payment does not exceed $600.00
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What will Section 111 Cost to Implement?
• CMS estimates it will take RREs approximately 375
hours to develop the administrative processes to comply
with Section 111.
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What will Section 111 Cost to Implement?
• However, compliance requires:
 Potential collection and entry of over 200 data
fields per claimant;
 Potential for 199 error codes;
 Ongoing Quarterly Reports;
 Internal Monitoring of an individual’s Medicare status
for ORM payments; and
 Failure to Report = $1000/day/claim.
© 2008 Smith Moore Leatherwood LLP. ALL RIGHTS RESERVED.
What will Section 111 Cost to Implement?
• CMS has developed strict guidance for reporting:
– Data must be reported in a certain form and format;
– Data must be converted into a “flat file” in ASCII format; and
– Data cannot be reported:
• in Excel;
• in Word; or
• In a manner that does not control every aspect of data entry
into the required field.
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Section 111 Medical Payments by Liability Entities
www.smlcompliance.com
Software is designed to drive proper data entry by:
• Restricting field inputs,
• Identifying errors with error reports,
• Formatting fields to the required specifications,
• Automatically creating the reports specified by CMS, and
• Importing the Medicare Response files and generating reports.
© 2008 Smith Moore Leatherwood LLP. ALL RIGHTS RESERVED.
Questions??
© 2008 Smith Moore Leatherwood LLP. ALL RIGHTS RESERVED.
Erin S. Zuiker
Smith Moore Leatherwood LLP
434 Fayetteville Street, Suite 2800
Raleigh, North Carolina 27601
T: (919) 755-8700
F: (919) 755-8800
Lisa K. Shortt
Smith Moore Leatherwood LLP
300 N. Greene Street, Suite 1400
Greensboro, North Carolina 17401
T: (336) 378-5200
F: (336) 378-5400
© 2008 Smith Moore Leatherwood LLP. ALL RIGHTS RESERVED.