Understanding the Exposure SCHIP Mandatory Insurer Reporting

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Understanding the Exposure SCHIP Mandatory
Insurer Reporting MSP Compliance

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Medicare Secondary Payer Act(MSP)

• Passed in 1980 42 USC 1395y and 42 CFR 411
• Legislative Intent Medicare will always be a
  Secondary Payer if a primary payer exists
• Primary Payers include Workers Compensation,
  Liability, Auto No Fault, USLH, Jones Act, and
  Group Health
• In July of 2001, CMS introduced the MSA Review
  and Approval process for certain WC settlements
• In December of 2007, SCHIP Extension Act was
  passed into law and affects all claims,
  settlements, judgements, awards involving
  Medicare beneficiaries

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Medicares Rights of Recovery

• There are 2 aspects to consider when protecting
  Medicares interests
• Conditional Payments (payments made by Medicare
  on behalf of the primary payer, liens)
• Future Payments (protection for Medicare against
  future payments that are the responsibility of a
  primary payer, the allocation)

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Conditional Payments

• Medicare may make conditional primary payer
  payments and seek reimbursement from the primary
  payer both pre and post Settlement, Judgment, or
  Award (S/J/A)
• Conditional payments must be resolved at the time
  of the S/J/A
• Conditional payments not reimbursed by the
  claimant within 60 days from S/J/A become the
  responsibility of the primary payer

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Future Payments

• Absent an allocation, CMS may require the
  claimant to spend the entire settlement amount on
  medical care
• If a settlement represents a deliberate attempt
  to shift burden, CMS may refuse to recognize the
  settlement (private cause of action)
• There are no Safe Harbors, every settlement
  must demonstrate adequate consideration of
  Medicares interests (an allocation)

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What is SCHIP all about?

• Section 111 of SCHIP serves 4 purposes
• Generate revenue through an estimated 1.1B in
  fines to fund State Children Health Insurance
  Programs
• Discover tens of billions in unresolved
  conditional payments and seek immediate recovery
  from Primary Payers
• Cease making ongoing conditional payments in the
  future
• Insure that all settlements adequately consider
  (allocate) Medicares interests as required by
  law
• Admission of liability not required to establish
  primary payer responsibility

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SCHIP and MSP Compliance

• SCHIP makes NO CHANGES in the WC MSA Review and
  Approval Program
• SCHIP brings an additional step to the WC MSA
  settlement in Class I beneficiary cases
• SCHIP is a separate and distinct program that
  runs in parallel with the MSP
• For Liability Auto settlements an allocation is
  indicated (Claims Settlement Allocation)

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Mandatory Insurer Reporting (MIR)

• Required on all NGHP (Liability, No-Fault, Self,
  WC)
• Requires that primary payers check Medicare
  beneficiary status on ALL claims quarterly
• Requires reporting of ALL claims involving
  Medicare beneficiaries quarterly
• Requires reporting S/J/As on ALL claims involving
  Medicare beneficiaries
• Contested cases exception
• Applicable regardless of whether or not future
  medicals are closed

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NGHP MIR Timeline

• RRE Registration between 5/1/09 and 9/30/09
• Only 1 reporting agent, TPA is not the RRE
• At time of registration, reporting date
  established
• Testing of data feed to CMS from 10/1/09 to
  3/31/10
• Ensures 180 field feed properly
• Requires massive claims system additions
• 1st live report between 4/1/10 and 6/30/10
• 1000/day/claim penalty begins
• Retroactive reporting required from 1/1/10

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RRE Registration

• Section 8 (pgs 22-26) NGHP User Guide
• Step 1
• Identify the Authorized Representative
• May not be an agent
• Must be able to contract on behalf of the RRE
• Identify the Account Manager
• May be an agent of the RRE
• Controls the administration of the RREs account
• Identify COBSW Users
• Manages the reporting process

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RRE Registration

• Step 2 Determine Reporting Structure
• How many RRE IDs are you planning on obtaining?
• Multiple RRE IDs
• 1 RRE ID 1 Reporting Agent 1 Quarterly Report
• Multiple RRE IDs 1 Reporting Agent Multiple
  Quarterly Reports
• Step 3 RRE Registration on the COBSW
• PIN RRE ID will be mailed to the Authorized
  Representative
• Step 4 RRE Account Set up on the COBSW
• May be done by the Account Manager
• Step 5 Authorized Representative Return Signed
  RRE Profile Report

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Protecting YOU

• RRE Claim System Modifications
• Mandatory Insurer Reporting (MIR) data fields
• Medicare Secondary Payer (MSP) data fields
• GL Solution
• Medicare Query Function (MQF)
• Mandatory Insurer Reporting (MIR) Compliance
• Medicare Secondary Payer (MSP) Compliance
• Extensive Training
• In-Person Webinar sessions to ensure each
  claims examiner understands requirements and data
  elements

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ISAR MIR Workflow

• Identify Check Medicare status on all claims
  every month
• Satisfy Research/negotiate and resolve
  conditional payments prior to S/J/A
• Allocate Future medicals in the S/J/A
• Report On all Medicare eligible claims, report
  the MIR data to CMS

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OneSource Solution

• GLs solution captures the fields required by
  CMS with additional fields to automate the
  routing of cases with MSP exposure
• Solution designed to hold cases in which
• Potential Conditional Payments exist
• An MSA with CMS approval is needed
• A demonstration of adequate consideration is
  indicated (CSA)
• The automated solution removes the need for the
  adjusters to make manual decisions regarding MSP
  compliance

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Contact Information

• 101 Riverfront Blvd, Suite 100
• Bradenton, FL 34205
• 866-672-3453 x 1077
• kip.daniels_at_gouldandlamb.com
• www.gouldandlamb.com