Transcript Infogix Webinar

Welcome
Ease Your Medicare Compliance Pains with
Automated Information Controls
The webinar will begin shortly.
To dial into the audio bridge: 1-408-600-3600
Event ID: 666 375 908
Copyright 2010 Infogix, Inc. All rights reserved.
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Speaker Introduction
 Jennifer S. Burke
 Partner, CassidaySchade, LLP
 Practice focused in the representation and counsel of
employers in workers’ compensation and Medicare SetAside matters
 Frequent author/speaker and member of the Illinois State
Bar Association, the Workers’ Compensation Lawyer’s
Association, the Illinois Association of Defense and Trial
Counsel, and the National Alliance of Medicare Set Aside
Professionals.
Jennifer S. Burke
 Dan Dopp
 Leader Customer Acquisition Group
 Over 15 years experience in Control Automation and
Continuous Monitoring
 Recognized expert and thought leader in Automated
Controls
Dan Dopp
Copyright 2010 Infogix, Inc. All rights reserved.
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Agenda
 Medicare Secondary Payer Act
 Who is impacted
 Typical Medical Reporting Scenario
 Automated Controls: Information Controls Framework
 Best Practices Going Forward
Copyright 2010 Infogix, Inc. All rights reserved.
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www.cassiday.com
Ease Your Medicare Compliance Pains with Automated Controls
Presented by:
Jennifer S. Burke, Partner
•
Chicago
•
Libertyville
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Naperville
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Rockford
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Chesterton
Medicare Secondary Payer Act
42 U.S.C. 1395y(b)(2)(A)(ii)
Medicare is precluded from paying medical expenses to the
extent that payment has been made or can reasonably be
expected to be made under a workers’ compensation law or
plan or under an automobile or general liability insurance
policy or plan or under no-fault insurance.
Became law December 5, 1980
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Section 111 of the MMSEA
(Medicare, Medicaid and SCHIP Extension Act of 2007)
Requires any entity making a payment to a Medicare
beneficiary to report that payment to CMS
Signed into law December 29, 2007 as an amendment to the
Medicare Secondary Payer Act
This will be the method by which CMS red flags any case in
which they might be entitled to a recovery of medical
payments
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MMSEA, 42 U.S.C. 1395y(b)(8)
WHO: Applicable plans must report
Applicable plans are defined as:
Liability insurance, including self-insurance
No fault insurance
Workers’ compensation laws or plans
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WHAT: Report the identity of a Medicare beneficiary
whose illness, injury, incident, or accident was at issue
as well as such other information specified by the
Secretary to enable an appropriate determination
concerning coordination of benefits, including any
applicable recovery claim.
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WHEN: In a form and manner specified by the Secretary
Information shall be submitted within a time specified by the
Secretary after the claim is resolved through a settlement,
judgment, award or other payment (regardless of whether
or not there is a determination or admission of liability)
Submissions will be in electronic format
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Further Defining “Who”
REQUIRED REPORTING ENTITIES (RREs)
Generally the insurer is the RRE
TPAs in a non-group health plan (NGHP) are never RREs
based solely on their TPA status
In cases involving multiple defendants you will likely have
multiple RREs and thus multiple reports
Can usually follow the responsibility for the payment to
determine the RRE
For further information regarding issues pertaining to
SIRs, deductibles, bankruptcy, acquisitions, foreign
insurers, insurance pools see the MMSEA User Guide,
Version 3.1
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Further Defining “What”
The Medicare beneficiary…
65 years of age
Receipt of Social Security Disability Insurance Benefits for
24 months
End stage Renal disease
All of these should be red flags for you when
determining which cases need to be reported.
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Have your attorney or claims representative ask Medicare
beneficiary questions in written and oral discovery
Provide the claimant with CMS’ model language on a yearly
basis:
www.cms.gov/MandatoryInsRep/Downloads/NGHHICN
SSNNGHPForm.pdf
Use the Query function
Document your efforts
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Defining an internal process for identifying Medicare
beneficiaries and securing the necessary information to
enable you to report is critical to compliance and
avoiding liabilities associated with non-compliance.
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Reports must be made without regard to liability. Any
payment must be reported, within certain thresholds
“Payment” is not limited to cash compensation. Anything
of monetary value can be considered payment
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Further Defining “When”
No-Fault Insurance
There is NO de minimis dollar threshold for reporting the
assumption/establishment of ORM or for reporting
TPOC
Liability Insurance ORM
There is NO de minimis dollar threshold for reporting the
assumption/establishment of ORM
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Workers’ Compensation ORM
Claims meeting all of the following criteria are excluded
from reporting for submissions through December 31,
2011
The claim is for “medical only” and
The “lost time” for the worker is no more than the number of
days permitted by the applicable workers’ compensation
law for a “medical only” claim or seven calendar days if
the law has no such limit and
All payment(s) has/have been made directly to the medical
provider and
Total payment for medicals does not exceed $750.00
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Liability Insurance and Workers’ Compensation TPOC
Amounts
Requirements:
TPOC thresholds do not apply to reported ORMs. If a case
with a reported ORM is under threshold it is reportable
at the RRE’s discretion. If over the threshold, it must be
reported
TPOC checks will apply only to add records
Add records which have no ORM and do not meet the total
TPOC threshold will be rejected with an error code
In the case of multiple TPOCs associated with the same
claim record, the combined, cumulative TPOC amounts
must be considered in determining whether or not the
reporting threshold is met. However, multiple TPOCs
must report in separate TPOC fields
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Only TPOC dates of 10/1/2010 and subsequent need be
reported. Prior dates are at the RRE’s discretion
The threshold dollar and date ranges apply to the date when
the threshold is met (the most recent TPOC date).
Timeliness of reports will be determined based upon the
applicable date for the TPOC which caused the
threshold to be met
For TPOCs involving a deductible, where the RRE is
responsible for reporting both any deductible and any
amount above the deductible, the TPOC amount
includes the total of these two figures which in turn is
included in the total TPOC amount used for the
threshold check
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Dollar and Date Thresholds
Claims where the last TPOC is prior to January 1, 2012
with TPOC totaling $0.00 - $5,000.00 are exempt
Claims where the last TPOC date is January 1, 2012
through December 31, 2012 with TPOC amounts
totaling $0.00 - $2,000.00 are exempt
Claims where the last TPOC date is January 1, 2013
through December 31, 2013 with TPOC amounts
totaling $0.00 - $600.00 are exempt
No threshold applies to claims where the last TPOC date is
subsequent to January 1, 2014
Copyright 2010 Cassiday Schade LLC. All rights reserved.
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Time Frames
Data collection should have already begun. Your first report
will include any items settled on or after 10/1/2010
If you registered, you were assigned a submission timeframe
for the first quarter of 2011. Your report must be
submitted properly in that window to be considered
timely
Reporting will continue on a quarterly basis thereafter
assuming you have claims to report
Use the EDI Representative assigned to you at registration.
They are there to help you through the process.
Communication is key!
If you have not registered but expect to have something to
report, you need to register with enough time to allow for
a test submission prior to the actual report
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ENFORCEMENT
42 U.S.C. 1395y(b)(8)(E)
A applicable plan that fails to comply with the requirements
under subparagraph (A) with respect to any claimant shall
be subject to a civil money penalty of $1000.00 for each
day of noncompliance with respect to each claimant.… A
civil money penalty under this clause shall be in addition
to any other penalties prescribed by law and in addition to
any Medicare secondary payer claim under this title with
respect to an individual.
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Typical Medicare Reporting Scenario
 Information prepared for CMS reporting must be
aggregated from multiple systems across multiple
platforms
 Information must be validated for completeness and
reasonability, in addition to being transformed into the
acceptable CMS universal format
 Gateway filters out transactions that do not meet CMS
data quality criteria.
 Responsibility rests with the reporting entity to record and
resubmit
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Typical Medicare Reporting Scenario
Claim System #1
CMS
Claim System #2
Gateway
Data
(CMS Format)
Claim Sys tem #3
Claim System #4
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Medicare Reporting Challenges
 Multiple Systems
 Multiple Platforms and Data Formats
 Batch and Real time source systems
 Error Monitoring
 Changes in Source Systems
 Changes in Reporting Requirements
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Typical Business Problems
 Reportable claims are lost in process and run the risk of
generating fines
 Information is incomplete/does not meet CMS
requirements
 Exceptions are not documented and are managed
ineffectively
 On going changes to CMS data elements requirements
are not implemented
 Duplicate/Missing information submitted
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Current Approach to Address Challenges
 Manual Balancing of information sent to CMS
 Logging activity into spreadsheets
 Email based exception management processes
 Embedded hard coded application controls
 Limited or Lack of Audit Trail
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Information Controls Framework:
Automated Controls
 Information sent to CMS reconciles with originating
source systems
 Claimant data sent is complete and consistent to
Mandatory Insurer Reporting Requirements
 Centralized management of all claims exceptions
pending delivery to CMS
 Error trending to increase operational efficiency
 Visibility and continuous monitoring information sent to
CMS
 Information is not duplicate and is reasonable
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Information Controls Framework
Claim System #1
CMS
Claims System #2
Data
Gateway
(CMS Format)
Claim System #3
Claim System #4
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Information Controls Framework:
Automated Information Controls
End-to-End Integrity
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Information Controls Framework:
Visibility - Controls Monitoring
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Information Controls Framework:
Visibility - Operational Intelligence
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Benefits of Automated Controls
 Avoid unnecessary fines by confirming all required
claims are sent to CMS
 Verify each claim contains complete and accurate
information as directed by CMS
 Reduce the Cost of MSP Compliance
 Increase visibility into Medicare Compliance process
 Be prepared for CMS reporting changes and
requirements
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Best Practices Game Plan
 Assess Risk
 Define/Design appropriate Controls
 Define Continuous Monitoring Needs
 Implement & Test
 Extend control best practices outside of MSP
Copyright 2010 Infogix, Inc. All rights reserved.
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Q&A
Copyright 2010 Infogix, Inc. All rights reserved.
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Thank you for participating!
For more information, please visit us at:
http://www.cassiday.com
For more information, please visit us at:
http://www.infogix.com
An archive of this event will be made available on the Infogix website
shortly. Any questions that were received but not answered
during the live broadcast will be answered via email.
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