HOW TO MANAGE THE MEDICAL SERVICES ACCOUNT (MSA) PROGRAMPresented by William Condon, Navy UBO Program Manager

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22 May 2012 0800-0900 EDT24 May 2012 1400-1500 EDT

Every day, tens of thousands of persons without Defense Health Program (DHP)-funded healthcare eligibility are treated in DoD MTFs. This brief will discuss:- Who are those persons?- How do we identify those persons/events?- Why do they have to pay?- What do we do to collect payment?- What do we do when payment does not occur?

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Purpose

Bottom line – whenever an MTF treats a non-beneficiary without obtaining reimbursement, that MTF diverts their DHP appropriation towards providing free healthcare to an unauthorized person. This impacts:

- The taxpayer, who pays for the excess appropriation- The MTF, which has fewer resources to spend on authorized beneficiaries- The authorized beneficiaries, who receive fewer services (in order to fund

the free healthcare for others)

This brief will help you ensure that neither the taxpayer, MTF or beneficiary suffer in order to fund the healthcare of non-authorized persons

10 U.S. Code (USC) Chapter 55- Part 1079(b) (Fees for civilian healthcare)

38 USC Chapter 81- Part 8111 (VA/DoD Resource Sharing)

31 USC Chapter 37- Part 3711 (Collection and Compromise)- Part 3717 (Interest and Penalties on Claims)- 31 USC Chapter 37 codifies Public Law (P.L.) 97-365 -- Debt Collection

Act (DCA) of 1982 and P.L. 104-134 -- Debt Collection Improvement Act (DCIA) of 1996

32 Code of Federal Regulations (CFR) Chapter 1- Part 108 (Healthcare eligibility under the Secretarial Designee Program)- Part 728 (Medical/Dental Care at Naval Facilities)

31 CFR Chapters 2 and 3- Parts 900-904 (Federal Claims Collection Standards (FCCS))- Part 285 (Debt Collection Authorities)

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Instructional sources

ID Cards/Eligibilities (DoDI 1000.13) (USD P&R) DEERS Procedures (DoDI 1341.2) (USD P&R) Financial Management Regulation (FMR) (DoD 7000.14-R)

- Vol 5 Ch 28 (Mgmt and Collection of Individual Debt)- Vol 5 Ch 24 (Electronic Commerce)- Vol 5 Ch 5 (Deposit/Transfer of Public Funds)- Vol 4 Ch 3 (Receivables)- Vol 11A Ch 1 and 3 (Reimbursement / Economy Act Orders)

UBO Manual (DoD 6010.15-M) DEERS checking policy (HA Policy 97-057) Billing/Collecting policy (HA Policy 08-007) Treasury Financial Manual (TFM) Bulletin 2011-09

(No-cash/check policies)

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Instructional sources

Patient

Registration

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Absent 32 CFR Ch. 1 Parts 108/728, DoD may not treat non-beneficiaries in its MTFs. However, the CFR provides DoD authority (to be used sparingly) to treat persons without a statutory entitlement. (statutory = U.S. Code)- But ---- “When used, it shall be on a reimbursable basis,

unless … Care is authorized by this Part (108); Reimbursement is waived by the Under Secretary of Defense

(Personnel and Readiness) (USD P&R)) Reimbursement is waived by the Secretary of the Military

Department

‘Reimbursable’ = Pay Patient = Medical Services Accounts (MSA) Program

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How the process works (regulatory / instructional perspective)

From 32 CFR Parts 108/728, USD P&R has produced two instructions (DoDIs 1000.13 and 1341.2). These two instructions:- Establish eligibility for healthcare services (and other services)- Establish DEERS as the repository for the eligibility data

Then, from the above DoDIs and DEERS data, TMA (UBU) has produced the CHCS PatCat table

Finally, Patient Admin Dept (PAD)/Front Desk Clerks use the DEERS data and/or DoDIs to appropriately register/verify patients (at each individual care episode)- HA 97-057 requires 100% DEERS checks- … However … as we all know, sometimes patients end up being

registered incorrectly …

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How the process works (regulatory / instructional perspective) (cont.)

The PatCat table and registration/verification process is not perfect. Examples:- Not all eligibilities are in DEERS (require DEERS overrides – document!)

Reservists on Active Duty VA Resource Sharing referral No DEERS should default to K92 (Civ Emerg) or K99 (Not Class Elsewhere),

unless specific override authority exists

- PAD and/or Front Desk Clerks use non-DEERS authority Non-MTF Commander-requested access

- Front Desk Clerks do not verify DEERS against the registered PatCat Occ Health patient (K57) returns for non-occ health visit

- PatCat table is incomplete PatCat holes (e.g. CONUS State Dept family member for Agency healthcare) PatCat diversion to the DD Form 7/7A

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Importance of the PatCat

If you have are seeing patients with no eligibility, ensure they are in a pay PatCat!

Who are

MSA patients?

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Any person without a DoD benefit for the service that they receive should be billed under the MSA program, incl:- US Coast Guard, NOAA, PHS (Agency pays/MOU)- VA patients seen for a referred service as part of a Resource Sharing

Agreement (Agency pays/MOU)- Foreign military not covered by a Reciprocal Healthcare Agreement (find

valid RHCAs at: https://private.fhp.osd.mil/portal/rhas.jsp)- OCONUS Civil Servants, contractors, DoD teachers, etc.- VA patients seen (but not thru a Resource Sharing Agreement) (individual

pay at the FRR/FOR rate)- Non-DoD Civil Servants/contractors seen for Occ Health services- DoD Civil Servants who receive non-occ health healthcare (even if

administered by the Occ Health Dept)- DoD Civil Servants who receive occ health care (outside of the Occ Health

Dept) without obtaining an Occ Health Dept referral- Possible NAF work-related healthcare (Service Secretary policies apply)

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MSA patients

MSA invoicable healthcare (cont.):- Persons mis-registered into a no-charge PatCat (incl. persons mis-

registered due to DEERS errors)- Cosmetic surgery for DoD beneficiaries- Foreign IMET military patients (Agency pays for healthcare listed in orders;

individual pay (FRR/FOR rate) for healthcare not listed in orders)- Civilian emergency patients (incl. Medicare and VA-covered patients) - Cafeteria meals/FMR charges (except for specified patrons, such as non-

retired family member inpatients, specified medical attendants, TRICARE Prime, wounded warriors)

Regardless of the DD 7/7A output, Agency billing is only a requirement if an MOU exists (normally executed via a DD Form 1144 (Support Agreement) / DD Form 448 (Military Interdepartmental Purchase Request)). Otherwise, individual billing (via a CHCS I&R) is appropriate. See FMR Vole 11A Chapters 1 & 3 (Reimbursable Work Orders / Economy Act Orders)

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MSA patients (cont.)

Debt

Generation /

Payment /

Transfer

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Healthcare rendered to patients in pay PatCats (both individual and Agency pay) will be routed to the Coding Dept for review.- Important: healthcare rendered to no-charge PatCat patients does not receive a

Coding Dept review After Coding Dept review, either an invoice will generate (for individual pay

PatCats), or the charges will appear on the DD 7/7A (for Agency pay PatCats)

Healthcare that must be billed manually (ensure Coder review occurs first, if it hasn’t already occurred):- Dental- Individual-pay encounters mis-routed to the DD 7/7A- Encounters documented under a no-charge PatCat- Encounters documented under a PatCat with the wrong rate- Cosmetic surgery

By reviewing a generated invoice for correctness, the UBO is meeting the FMR requirement to ‘confirm’ the existence of a debt (see next slide …)

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CHCS Invoice Production

FMR (Vol 5 Ch 28)/FCCS merely requires one demand letter- Demand letters must be issued within 5 working days after ‘debt

confirmation’ Letters may be mailed or hand delivered (special handling – e.g. FedEx or

certified mail – is never req’d) A CHCS I&R suffices as a demand letter Lack of an address is not cause to non-confirm the debt

- Healthcare for which a patient has provided the MSA Officer insurance information need not be confirmed (for Vol 5 Ch 28 purposes) until the invoice is 180 days old (UBO Manual, para C3.18 and C3.30.3.1).

After 180 days, the MTF must terminate insurance collection efforts, and confirm the debt (or the remaining portion unpaid by the insurance company)

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Debt certification

There are no provisions in the USC, CFR or DoD instruction to ‘waive’ co-pays/deductibles/non-covered charges for any MSA invoice, regardless of the payer (incl. Medicare or the VA)

- Payment is normally due within 30 days of confirming the debt Debts not paid by the due date are delinquent Debtor may enter into a payment plan

- Debts on a payment plan are not delinquent Delinquent debts are subject to Penalties, Interest and Admin fees

(per FMR Vole 5 Ch 28 section 2806 and Vol 4 Ch 3 Ann 1) Debts that are 60 days delinquent, require transfer to the Debt and

Claims Management Office (DCMO – DFAS) Debts are payable, and become delinquent, regardless of the validity

of the address on file- Normally, mail to the DEERS address; it is not the responsibility of either

the MTF or UBO to ensure that the patient has updated DEERS

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Debt certification (cont.)

As per the Debt Collection Improvement Act (DCIA), all debts must be referred to Treasury once they are 180 days delinquent

Debts are not considered as paid until funds are deposited to the Treasury and/or transferred to the correct line of accounting. Collection Agents can receive payment via the following FMR-compliant (FMR Vol 5 Ch 24) methods:

- Cash (note that U.S. Treasury policy (TFM 11-09) allows Agencies to establish no-cash/no-check policies)

Cash may also converted to cashier’s checks- Paper checks (paper checks may be deposited to a Treasury General Account (TGA) bank,

or via scanning thru the Over the Counter Channel Application (OTCnet))- Electronic checks (thru Pay.gov)- Credit/Debit cards (thru Pay.gov)- Electronic funds transfer (EFT) (thru Credit Gateway)- Intra-Governmental Payment and Collection (IPAC) system- DFAS pay garnishment (using a DD Form 2481 (Salary Offset) or a DD Form 139 (Pay

Adjustment))- Confirm deposits (incl. returned checks) via CA$HLINK II (soon to be replaced by the

Transaction Reporting System (TRS)); liaise with your DFAS for method to confirm IPACs/DD Form 1131 postings/DD Form 2481 collections (for DFAS-CL sites - use the Cash History Online Operator Search Engine (CHOOSE))

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Payments

Remember – the FMR Vol 5 Ch 5 (Deposit of Public Funds) requires same-day/ next-day deposit any time funds on hand exceed $5,000 (funds are cash or checks)

Delinquent debts older than 180 days must be transferred to Dept of Treasury. MTFs may do this by:

- Directly transferring via the Treasury’s FedDebt program FedDebt is being piloted at Naval Hospital Jacksonville; TMA

coordinating usage by all MTFs Service training

- Transfer to DFAS-Indianapolis (out-of-service debts) DFAS-IN only accepts debts greater than $225 Transfer packages should go to: DFAS-IN-DEBT_MGMT@dfas.mil Transfer should occur once debt is 60 days delinquent DFAS-IN will transfer the debt to Treasury at 180 days

To avoid transfer, the MTF must receive payment, or establish debtor on a payment plan- Payment plans must be less than 3 years, and at least $50 per month- Successfully processed DD Forms 139/2481 suffice for

payment/payment plans17

Delinquent Debts

Not later than 2 years of age, delinquent debts must be written off from the MTF’s financial statements. Write-off normally occurs when a debt has been transferred to Treasury or DFAS - Transferred debts are considered as Currently Not Collectible (CNC).

Debts may remain in a CNC status for an indefinite period of time. (CHCS acct status – ‘F’/’T’)

CNC debts are subject to continuing collection efforts

- Non-transferred debts (less than $225) must be written-off and closed-out within 1 year (CHCS acct status – ‘W’)

Closed-out debts are not subject to further collection efforts The $225 limit is not to be considered as authority for the MTF to grant ‘free’

healthcare; MTFs must pursue collection of sub-$225 accounts

- At the discretion of the debt holder (DFAS and/or MTF), CNC debts may be closed-out

Closing out a debt generates Treasury production of an IRS Form 1099-C (Income due to Discharged Debt)

- Debts with a CHCS ‘F’/’T’ status may have payments applied, by changing the status to ‘R’ (payments cannot be applied towards ‘W’ accts).

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Write-off / Close-out

Debts transferred to FedDebt (or to DFAS for further transfer to FedDebt) result in the following actions:- An initial demand letter to the debtor- After 30 days:

Addition of a 28% debt handling fee Addition of interest and penalties Reporting of the debt to the Treasury Offset Program (TOP)

- TOP can offset virtually any Federal payment (e.g. Federal salaries, Social Security payments, tax returns)

- Debts remain in TOP forever Reporting to credit bureaus Referral to Private Collection Agencies (for 540 days)

- Upon a DFAS/MTF decision (after at least 540 days): Generation of an IRS Form 1099-C

- FedDebt payment recoveries are returned to DFAS/MTF (except for the 28% handling fee)

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Treasury FedDebt

Misc items to consider

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Purpose

Filing insurance claims for MSA patients is a courtesy; not mandated- Filing of a claim does not relieve the patient of the responsibility to

ultimately pay 100% of the bill- Terminate insurance actions at 180 days; do not allow patients to dictate

that you must continue insurance actions for an indefinite period of time- Unsatisfactory insurance processing is an issue for the patient to resolve,

not the UBO/MSA Officer

For additional assistance, consider using support authorized by HA Policy 08-007: - A non-CHCS system, such as a standalone/web-based claims filing

medical clearinghouse- Contract support- Support from a larger MTF

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Items to consider

Point of Contact:

William (Bill) Condon

Navy UBO Program Manager

william.condon@med.navy.mil

(202) 762-3566

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Point of Contact

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Instructions for CEU Credit, cont.

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