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Briefing: Medical Affirmative Claims – How should MAC work? Date: 21 March 2007 Time: 1610 - 1700 PowerPoint Presentation
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Briefing: Medical Affirmative Claims – How should MAC work? Date: 21 March 2007 Time: 1610 - 1700. Objectives. Identify Legal Authority requiring Medical Care Recovery / Medical Affirmative Claims (MAC) Identify what is included in the MAC Program

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briefing medical affirmative claims how should mac work date 21 march 2007 time 1610 1700
Briefing: Medical Affirmative Claims – How should MAC work?

Date: 21 March 2007

Time: 1610 - 1700

objectives
Objectives
  • Identify Legal Authority requiring Medical Care Recovery / Medical Affirmative Claims (MAC)
  • Identify what is included in the MAC Program
  • Identify how to improve the identification and collection of MAC information
  • Identify the requirements of the MAC Billers in the MTF
  • Identify requirements of the NLSO Claims Office – JAG Code 15
  • Identify reporting requirements
  • Identify the Charge Master Based Billing system will impact MAC
legal authority
Legal Authority
  • Federal Medical Care Recovery Act (42 U.S. Code, Chapter 32, Sections 2651 – 2653)
  • Collections From Third Party Payers (10 U.S. Code, Chapter 55, Section 1095
  • Federal Claims Collections Act (31 U.S. Code, Chapter 37, Section 3711)
  • Worker’s Compensation Statutes - Federal and State
what is included in the mac program
What is included in the MAC Program?
  • Motor Vehicle Accidents - Automobile, Motorcycle, Boating, etc., caused by another party or the beneficiary injured
  • Personal Injuries – Slip & Falls, Dog Bites, etc.
  • Product Liability – Silicone Breast Implants, Phen Phen Diet Pills, etc.
  • Medical Malpractice – suit is against a civilian hospital, or private medical practice. Treatment/care to correct/repair was provided by the MTF
  • Worker’s Compensation – Treatment/care provided to beneficiaries for work related injuries. Does not include care/treatment provided to Federal employees or Active Duty Military Personnel who are injured on their DoD job
who is responsible
Who Is Responsible?
  • Everyone in the MTF is responsible for the success of the MAC Program, but the UBO is responsible for overseeing the MAC Program at the MTF
  • UBO MAC staff must provide training to all of the departments/clinics/ancillary services in the MTF on how to identify “potential” MAC cases
  • The UBO must provide the department/clinics/ ancillary services with the MAC questionnaires to be completed by the patient
duties of the mac biller
Duties of the MAC Biller
  • Train and maintain a relationship with the front desk staff in the various clinics, ancillary services throughout the MTF, especially in the ER and Admission Office
  • Obtain completed MAC questionnaires and determine if there is a potential MAC case
  • Receive requests for Medical/Dental care costs from civilian attorney’s, insurance companies, and military legal offices (All requests should be coming via the NLSO)
  • Identify all inpatient care, outpatient care, and ancillary services provided to the patient since the Date of Accident/Injury/Illness that are related to the injury / illness
  • Obtain all medical records and other documentation supporting the care/services identified as related to the injury / illness
duties of the mac biller con t
Duties of the MAC Biller (con’t)
  • Generate the appropriate claim form(s) / invoice to be provided to the NLSO, Army JAG, or Air Force JAG responsible for adjudicating the government’s claim
  • Maintain a file (electronic or paper) of all claims/invoice submitted to the NLSO, Army JAG, or Air Force JAG, including all documentation submitted with the claim(s) / invoice
  • Maintain a claims tracking system, identifying all claims submitted, where they were submitted, original amount of the claims submitted, and the actual amount collected, and reason for any adjustment or denial
  • Submit reports to the BUMED Regional UBO Program Managers
nlso responsibilities
NLSOResponsibilities
  • Receive all incoming request for costs of Medical Care from Civilian attorneys and insurance companies
  • Obtain a signed agreement from civilian attorney’s that state they will represent the interests of the government. Placing the attorney/insurance company on notice that the government will have a claim if any medical/dental care was provided by the MTF related to the accident/injury
  • Forward requests and all additional documentation to the MAC Office
  • Forwards all claims/invoices to the appropriate attorney and or insurance company in a timely manner to comply with the statute of limitations pertaining to that claim/case
  • Collect all monies due to the government, depositing the collections to the correct Line of Accounting (LOA) for the MTF that submitted the claim/ invoice
nlso responsibilities con t
NLSO Responsibilities (Con’t)
  • Provide monthly reports to BUMED Regional UBO Program Manager, identifying claims received, amount billed, amount collected, claims closed, and reason for receipt of less than 100% of what was billed or total denial
  • Meet with the BUMED Regional UBO Program manager and Legal Officer to discuss compromised claims, claims closed without collections, and develop process improvements
summary
Summary
  • Be knowledgeable of the legal authority requiring Medical Care Recovery / Medical Affirmative Claims (MAC)
  • Know exactly what is included in the MAC Program so that you don’t waste time generating claims that will never be pursued
  • Work with the clinics and ancillary services in your MTF to identify and collect MAC information
  • Work with the NLSO Claims Office – don’t waste time creating and sending them claims they will never pursue
  • Only with the information we are collecting on the MAC Tracking spreadsheet can we prove what is being sent to NLSO for processing
  • Be patient, the Charge Master Based Billing system is coming and will include MAC. CMBB will have the same billing capabilities and reports as MSA and TPC