MMSEA Section 111 Bulletin:
December 14th CMS Technical & Policy Call
The Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) held a Town Hall Teleconference on Wednesday, December 14, 2011. This Town Hall Teleconference addressed policy and technical concerns associated with Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) reporting. The following items discussed on the call merit notice to ISO and Crowe Paradis customers:
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Announcements – Jeremy Farquhar (COBC) reminded the attendees that CMS’ new gradual liability TPOC reporting directives begin on January 1, 2012 with respect to liability TPOCs on or after October 1, 2011 as more specifically outlined in CMS’ recent 9/30/11 Alert. CMS also reported that a new NGHP User Guide will be issued shortly which will basically incorporate the Alerts which have been issued since release of the current User Guide back in August.
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Conditional Payment Questions – CMS confirmed that a Rights and Responsibilities Letter (RRL) will be sent following the filing of a Section 111 claim report. With respect to claims where there will only be a TPOC report filed (i.e., following claim settlement), CMS reminded the industry that in order to obtain conditional payment information prior to settlement (and prior to the Section 111 report) the parties must follow the separate COBC/MSPRC reporting and request processes related to conditional payments. As always, ISO and Crowe Paradis encourage claims payers to initiate a conditional payment investigation as soon as a Medicare beneficiary is identified. This process provides maximum time to evaluate the conditional payment amount and take action to reduce it before settlement.
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Section 111 Penalties – CMS advised that it had no information to provide at this time about an expected timeline to release Section 111’s penalty provisions. The agency indicated that it would address the penalty provisions through the formal rule making/comment process. In the interim, CMS stressed that its primary emphasis remains on data collection.
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Workers’ compensation indemnity periodic payments and settlements – There were several questions regarding CMS’ reporting directives involving periodic indemnity payments and indemnity-only workers’ compensation settlements where ORM remains open. CMS referred the industry to p. 114 of the current NGHP User Guide. In general, CMS stated that if ORM had previously been reported, and continues following the indemnity-only settlement, then the RRE would not need to report the periodic or lump sum indemnity payment unless the medicals terminate.
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TPOC settlement involving loss of consortium claim – For TPOC settlements that include a single payment in satisfaction of separate claims from the same incident (i.e., a husband suffers an injury and his wife has a corresponding loss of consortium claim), CMS advised that the full settlement amount must be reported regarding each plaintiff regardless of whether or not the settlement contains a specific allocation of the settlement funds between the plaintiffs, or is unallocated. If only one plaintiff is a Medicare beneficiary, the full settlement amount must be reported for that plaintiff. CMS stated in these situations they will address and clarify any issues pertaining to recovery actions on the back end. Should you have a claim of this type, ISO and Crowe Paradis encourage complete documentation of the action you take in order to provide CMS with the required information.
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ORM termination and appeals – A question was raised regarding how the RRE should terminate ORM in a situation where upon appeal it was ruled that the RRE is not, or is no longer, responsible for the claimant’s injuries. CMS advised that the RRE should file a “delete” record only if under the appellate ruling the RRE is able to recoup the loss expenditures it issued during the ORM period. If the RRE is not able to recoup its expenditures, then an “ORM Termination” filing must be submitted reflecting the date of the appellate determination. (For information on ORM reporting and appeals, see page 116 of the current NGHP User Guide).
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Exposure Claims - Several callers presented specific fact patterns related to exposure claims and the 12/5/80 date. CMS discussed these situations in general terms but ultimately directed the industry back to specific criteria and examples in its 10/11/11 Alert (dealing with Exposure, Ingestion and Implantation) to determine reporting obligations.
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CMS Denial of Medical Treatment – Once again, several callers advised of an increasing number of reported instances where Medicare has denied treatment for non-claim related injuries. These denials of treatment are believed to be the result of Section 111 ORM claim reports. It was further reported that COBC is advising these claimants to obtain a letter confirming from the RRE that the case is “closed.” CMS stated that this is not proper procedure and reported that it recently provided education and instructions to its contractors on this point. In the interim, CMS encouraged the industry to continue to alert it of these types of situations.
Those were the primary issues discussed during the teleconference. At this time, CMS does not have any Town Hall conferences set for 2012. CMS instructed the industry to periodically check the Section 111 website for the posting of 2012 Town Hall teleconference dates.
For more information, please contact the ISO Customer Support Center at 1-800-888-4476 or at ClaimSearchMSP@iso.com, or contact your Crowe Paradis representative or email mspnavigator@cpscmsa.com.
Crowe Paradis and ISO are members of the Verisk Insurance Solutions group at Verisk Analytics. For more information, visit www.iso.com and www.cpscmsa.com.
