to dial into the audio bridge 1 408 600 3600 event id 666 375 908 n.
Skip this Video
Loading SlideShow in 5 Seconds..
To dial into the audio bridge : 1-408-600-3600 Event ID: 666 375 908 PowerPoint Presentation
Download Presentation
To dial into the audio bridge : 1-408-600-3600 Event ID: 666 375 908

Loading in 2 Seconds...

play fullscreen
1 / 35

To dial into the audio bridge : 1-408-600-3600 Event ID: 666 375 908 - PowerPoint PPT Presentation

  • Uploaded on

To dial into the audio bridge : 1-408-600-3600 Event ID: 666 375 908. Welcome. Ease Your Medicare Compliance Pains with Automated Information Controls. The webinar will begin shortly. Speaker Introduction. Jennifer S. Burke Partner, CassidaySchade, LLP

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'To dial into the audio bridge : 1-408-600-3600 Event ID: 666 375 908' - akio

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
to dial into the audio bridge 1 408 600 3600 event id 666 375 908
To dial into the audio bridge: 1-408-600-3600

Event ID: 666 375 908


Ease Your Medicare Compliance Pains with

Automated Information Controls

The webinar will begin shortly.

speaker introduction
Speaker Introduction
  • Jennifer S. Burke
    • Partner, CassidaySchade, LLP
    • Practice focused in the representation and counsel of employers in workers’ compensation and Medicare Set-Aside matters
    • Frequent author/speaker and member of the Illinois State Bar Association, the Workers’ Compensation Lawyer’s Association, the Illinois Association of Defense and Trial Counsel, and the National Alliance of Medicare Set Aside Professionals.
  • Dan Dopp
    • Leader Customer Acquisition Group
    • Over 15 years experience in Control Automation and Continuous Monitoring
    • Recognized expert and thought leader in Automated Controls

Jennifer S. Burke

Dan Dopp


Medicare Secondary Payer Act

Who is impacted

Typical Medical Reporting Scenario

Automated Controls: Information Controls Framework

Best Practices Going Forward


Ease Your Medicare Compliance Pains with Automated Controls

Presented by:

Jennifer S. Burke, Partner

  • Chicago
  • Libertyville
  • Naperville
  • Rockford
  • Chesterton

Medicare Secondary Payer Act

  • 42 U.S.C. 1395y(b)(2)(A)(ii)

Medicare is precluded from paying medical expenses to the extent that payment has been made or can reasonably be expected to be made under a workers’ compensation law or plan or under an automobile or general liability insurance policy or plan or under no-fault insurance.

Became law December 5, 1980

section 111 of the mmsea medicare medicaid and schip extension act of 2007
Section 111 of the MMSEA(Medicare, Medicaid and SCHIP Extension Act of 2007)
  • Requires any entity making a payment to a Medicare beneficiary to report that payment to CMS
  • Signed into law December 29, 2007 as an amendment to the Medicare Secondary Payer Act
  • This will be the method by which CMS red flags any case in which they might be entitled to a recovery of medical payments
mmsea 42 u s c 1395y b 8
MMSEA, 42 U.S.C. 1395y(b)(8)
  • WHO: Applicable plans must report
  • Applicable plans are defined as:
  • Liability insurance, including self-insurance
  • No fault insurance
  • Workers’ compensation laws or plans
WHAT: Report the identity of a Medicare beneficiary whose illness, injury, incident, or accident was at issue as well as such other information specified by the Secretary to enable an appropriate determination concerning coordination of benefits, including any applicable recovery claim.
WHEN: In a form and manner specified by the Secretary
  • Information shall be submitted within a time specified by the Secretary after the claim is resolved through a settlement, judgment, award or other payment (regardless of whether or not there is a determination or admission of liability)
  • Submissions will be in electronic format
further defining who
Further Defining “Who”
  • Generally the insurer is the RRE
  • TPAs in a non-group health plan (NGHP) are never RREs based solely on their TPA status
  • In cases involving multiple defendants you will likely have multiple RREs and thus multiple reports
  • Can usually follow the responsibility for the payment to determine the RRE
  • For further information regarding issues pertaining to SIRs, deductibles, bankruptcy, acquisitions, foreign insurers, insurance pools see the MMSEA User Guide, Version 3.1
further defining what
Further Defining “What”
  • The Medicare beneficiary…
  • 65 years of age
  • Receipt of Social Security Disability Insurance Benefits for 24 months
  • End stage Renal disease
  • All of these should be red flags for you when determining which cases need to be reported.
Have your attorney or claims representative ask Medicare beneficiary questions in written and oral discovery
  • Provide the claimant with CMS’ model language on a yearly basis:
  • Use the Query function
  • Document your efforts
Defining an internal process for identifying Medicare beneficiaries and securing the necessary information to enable you to report is critical to compliance and avoiding liabilities associated with non-compliance.
Reports must be made without regard to liability. Any payment must be reported, within certain thresholds
  • “Payment” is not limited to cash compensation. Anything of monetary value can be considered payment
further defining when
Further Defining “When”
  • No-Fault Insurance
  • There is NOde minimis dollar threshold for reporting the assumption/establishment of ORM or for reporting TPOC
  • Liability Insurance ORM
  • There is NOde minimis dollar threshold for reporting the assumption/establishment of ORM
workers compensation orm
Workers’ Compensation ORM
  • Claims meeting all of the following criteria are excluded from reporting for submissions through December 31, 2011
  • The claim is for “medical only” and
  • The “lost time” for the worker is no more than the number of days permitted by the applicable workers’ compensation law for a “medical only” claim or seven calendar days if the law has no such limit and
  • All payment(s) has/have been made directly to the medical provider and
  • Total payment for medicals does not exceed $750.00
liability insurance and workers compensation tpoc amounts
Liability Insurance and Workers’ Compensation TPOC Amounts
  • Requirements:
  • TPOC thresholds do not apply to reported ORMs. If a case with a reported ORM is under threshold it is reportable at the RRE’s discretion. If over the threshold, it must be reported
  • TPOC checks will apply only to add records
  • Add records which have no ORM and do not meet the total TPOC threshold will be rejected with an error code
  • In the case of multiple TPOCs associated with the same claim record, the combined, cumulative TPOC amounts must be considered in determining whether or not the reporting threshold is met. However, multiple TPOCs must report in separate TPOC fields
Only TPOC dates of 10/1/2010 and subsequent need be reported. Prior dates are at the RRE’s discretion
  • The threshold dollar and date ranges apply to the date when the threshold is met (the most recent TPOC date). Timeliness of reports will be determined based upon the applicable date for the TPOC which caused the threshold to be met
  • For TPOCs involving a deductible, where the RRE is responsible for reporting both any deductible and any amount above the deductible, the TPOC amount includes the total of these two figures which in turn is included in the total TPOC amount used for the threshold check
Dollar and Date Thresholds
  • Claims where the last TPOC is prior to January 1, 2012 with TPOC totaling $0.00 - $5,000.00 are exempt
  • Claims where the last TPOC date is January 1, 2012 through December 31, 2012 with TPOC amounts totaling $0.00 - $2,000.00 are exempt
  • Claims where the last TPOC date is January 1, 2013 through December 31, 2013 with TPOC amounts totaling $0.00 - $600.00 are exempt
  • No threshold applies to claims where the last TPOC date is subsequent to January 1, 2014
Time Frames
  • Data collection should have already begun. Your first report will include any items settled on or after 10/1/2010
  • If you registered, you were assigned a submission timeframe for the first quarter of 2011. Your report must be submitted properly in that window to be considered timely
  • Reporting will continue on a quarterly basis thereafter assuming you have claims to report
  • Use the EDI Representative assigned to you at registration. They are there to help you through the process. Communication is key!
  • If you have not registered but expect to have something to report, you need to register with enough time to allow for a test submission prior to the actual report
  • 42 U.S.C. 1395y(b)(8)(E)
  • A applicable plan that fails to comply with the requirements under subparagraph (A) with respect to any claimant shall be subject to a civil money penalty of $1000.00 for each day of noncompliance with respect to each claimant.… A civil money penalty under this clause shall be in addition to any other penalties prescribed by law and in addition to any Medicare secondary payer claim under this title with respect to an individual.
typical medicare reporting scenario
Typical Medicare Reporting Scenario
  • Information prepared for CMS reporting must be aggregated from multiple systems across multiple platforms
  • Information must be validated for completeness and reasonability, in addition to being transformed into the acceptable CMS universal format
  • Gateway filters out transactions that do not meet CMS data quality criteria.
  • Responsibility rests with the reporting entity to record and resubmit


(CMS Format)

Typical Medicare Reporting Scenario

Claim System #1


Claim System #2


Claim Sys tem #3

Claim System #4

medicare reporting challenges
Medicare Reporting Challenges

Multiple Systems

Multiple Platforms and Data Formats

Batch and Real time source systems

Error Monitoring

Changes in Source Systems

Changes in Reporting Requirements

typical business problems
Typical Business Problems
  • Reportable claims are lost in process and run the risk of generating fines
  • Information is incomplete/does not meet CMS requirements
  • Exceptions are not documented and are managed ineffectively
  • On going changes to CMS data elements requirements are not implemented
  • Duplicate/Missing information submitted
current approach to address challenges
Current Approach to Address Challenges

Manual Balancing of information sent to CMS

Logging activity into spreadsheets

Email based exception management processes

Embedded hard coded application controls

Limited or Lack of Audit Trail

information controls framework automated controls
Information Controls Framework:Automated Controls
  • Information sent to CMS reconciles with originating source systems
  • Claimant data sent is complete and consistent to Mandatory Insurer Reporting Requirements
  • Centralized management of all claims exceptions pending delivery to CMS
  • Error trending to increase operational efficiency
  • Visibility and continuous monitoring information sent to CMS
  • Information is not duplicate and is reasonable


(CMS Format)

Information Controls Framework

Claim System #1


Claims System #2


Claim System #3

Claim System #4


Information Controls Framework:

Visibility - Controls Monitoring



Information Controls Framework:

Visibility - Operational Intelligence


benefits of automated controls
Benefits of Automated Controls

Avoid unnecessary fines by confirming all required claims are sent to CMS

Verify each claim contains complete and accurate information as directed by CMS

Reduce the Cost of MSP Compliance

Increase visibility into Medicare Compliance process

Be prepared for CMS reporting changes and requirements

best practices game plan
Best Practices Game Plan
  • Assess Risk
  • Define/Design appropriate Controls
  • Define Continuous Monitoring Needs
  • Implement & Test
  • Extend control best practices outside of MSP

Thank you for participating!

For more information, please visit us at:

For more information, please visit us at:

  • An archive of this event will be made available on the Infogix website shortly. Any questions that were received but not answered during the live broadcast will be answered via email.

Company, product, brand, and mark names and logos herein are the property of their respective owners.

For a list of Infogix trademarks, visit: