new mandatory medicare insurer reporting requirements of section 111 of the medicare, medicaid &...
TRANSCRIPT
New Mandatory Medicare Insurer Reporting
Requirements of Section 111 of the Medicare,
Medicaid & SCHIP Extension Act (MMSEA)
An Insurer Perspective on the Challenges
Disclaimer
Information contained herein is not intended as, nor does it constitute, legal or professional advice, nor is it an endorsement of any source cited or information provided.
In no event will Travelers or any of its subsidiaries and affiliates be liable in contract or in tort to anyone who has access to this presentation for the accuracy or completeness of the information relied upon in the preparation of this presentation or for the completeness of any recommendations from cited sources. Participants should consult source material for more detail.
Travelers disclaims all warranties whatsoever.
2© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.
Objective
Provide an Insurer perspective on MMSEA challenges:
1. Obtaining the SSN or HICN
2. Defining the Responsibly Reporting Entity (RRE)
3. Registration & Reporting Hurtles
4. Data - the Devil in the Details
5. Defining a Responsible Insurer
1. The almighty SSN or HICN
• Lack of Cooperation
- Can we withhold payments?
- Bad faith from simply asking?
- Insurance Department complaints?
- Web portals like E Verify?
- How do we prove “due diligence” in collecting the SSN or HICN?
• Non U.S. Citizens
- Is a Query even necessary?
• Beneficiary under another SSN
- How to obtain a spouse’s or parent’s SSN?
© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.
2. Defining the RRE
In the casualty insurance world, “self-insured” is defined as assuming the risk of loss without the protection or backing of an insurance policy.
CMS will consider you to be “self-insured” to the extent of your financial responsibility in the settlement, whether you are truly self-insured or under a deductible plan.
© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.
2. Defining the RRE under Insurance Plans
If the Entity is insured under a…
The RRE for that Entity is…
Guaranteed Cost or Retrospectively Rated
Insurance Policy
Insurer within the insurance coverage as long as the insurer is making all payments to the beneficiary.
Deductible Insurance Policy
(Payments made to claimant by the Insurer)
Insurer within or over the deductible as long as the Insurer pays and seeks reimbursement from the insured.
Deductible Insurance Policy
(Payments made to claimant by the Insured)
Insured within or over the deductible.
Insurer becomes the RRE only if it assumes payment.
© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.
If the Entity is insured under a…
The RRE for that Entity is…
Self-Insured Plan
(Self or TPA Administration)
Self-Insured for all amounts within the SIR.
Excess Insurance Policy
(Payments made to the claimant by the Excess
Insurer)
Self-Insured for amounts within the SIR layer.
Excess Insurer for amounts paid to the claimant in the excess layer.
Excess Insurance Policy
(Payments made as reimbursement to Self-Insured)
Self-Insured for amounts it pays within and in excess of the SIR when excess carrier reimburses the self-insured for excess loss rather than paying it directly to the claimant.
2. Defining the RRE under true Self-Insurance
© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.
3. Data – the devil in the detail
35 to potential of over 70 on a single claim:
• Record ID: 3
• Demographics: 10
• Attorney: 0 – 11
• Payments: 5
• Insurance: 15 – 20 (contact fields)
• Medical: 2 – 20 (ICD9 & E Codes)
© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.
4. Reporting & Registration Hurtles
• Reporting
- How far back do you go?
- What about Medical Bill write-offs?
• Registration
- How many ID & PINs are needed?
- How much detail is needed on subsidiaries?
- How helpful is EDI Representative assistance?
© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.
5. A Responsible Insurer
• Provide detailed feedback, inquiries, suggestions and criticisms to CMS, both directly and through AIA.
• Prepare detailed claim system upgrades, workflows, and protocols to report to CMS as either an RRE or Reporting Agent for customers.
• Provide Webinars for customers that are also available for replay on the insurer’s Website.
• Prepare and distribute specific instructions, including CMS screen prints, on how to register as an RRE to self-insured customers.
• Provide months of internal educational sessions for all Claim Professionals who handle bodily injury claims all lines of casualty insurance.
© 2009 The Travelers Companies, Inc. All rights reserved. Ed. 07-09.