by Frank Fairchok, Vice President of Medicare Reporting Services

As previewed in our blog on February 26, the Centers for Medicare & Medicaid Services (CMS) hosted a town hall meeting that included staff from both the Benefits Coordination & Recovery Center (BCRC) and Commercial Repayment Center (CRC) last Thursday, April 1, 2021.  While the session began with a review of responsibilities for each contractor, along with a discussion of a “hot topic” for each, it was largely a question and answer session giving responsible reporting entities (RREs) the opportunity to submit questions ahead of time, or ask them live on the call.

First, John Albert presented a slide titled “Non-Group Health Plan Responsibilities” with information regarding each contractor and advice for resolution of issues as follows:

  • BCRC: Non-Group Health Plan (NGHP) recovery of conditional payments where a beneficiary is the identified debtor.
  • CRC: NGHP recovery of conditional payments where an insurer/workers’ compensation entity is the identified debtor.
  • Use correspondence received to ensure you are contacting the correct contractor for questions and be certain that any checks are made out to the appropriate contractor using the correct address as found on the Contacts page on CMS.gov.

 

ORM Status Changes
Next, the “Hot Topic” presented by Angel Pagan of the BCRC addressed several scenarios where the ongoing responsibility for medicals (ORM) status for multiple ICD codes changed for a claim. Except for one new event scheduled for release in June, these scenarios are all documented, along with many others, in the Event Table found in section 6.6.4 of the NGHP User Guide 6.2 (Chapter IV – Technical Information).

The new event details reporting treatment for a claim where ORM existed with multiple injuries and a total payment obligation to the claimant (TPOC) partially resolves ORM. In this scenario, the proper procedure includes sending an update against the ORM record to remove ICD codes for the resolved injury, while submitting a new add record to report the TPOC with the resolved ICD codes.

Of note was a scenario where the ORM status of a claim began with multiple injuries and related ICD codes, but changed over time so that some of the codes should no longer be included in the ORM. In this case, the ORM termination date is not populated until all codes are resolved. CMS advises that an “update” action type should be used in this scenario to remove those ICD codes where ORM has ended, leaving only the ICD codes where ORM remains active on the report.

While this approach seems simple enough, from a technical and process perspective, it elicits quite a few concerns. The first is how the CRC can manage this data with any accuracy as the updates removing ICD codes do not reflect individual ORM terminations. At best, the CRC may use the date of the claim record update to approximate which RRE is no longer responsible for an individual code (if the update was processed in a somewhat timely fashion). In addition, it is unlikely that most RREs have a system capable of controlling each of the nineteen possible ICD codes with that level of precision.

As one potential area for Section 111 Civil Money Penalties (CMPs) involves a situation where reported data does not match recovery related information, this should be a cause for concern for responsible reporting entities. While CMS has yet to define a complete strategy around CMPs, there are several scenarios that come to mind which could cause concern for RREs. Until we understand the proposed rule more completely, a strong and concise program for reviewing and resolving conditional payments is a must in order to protect the interests of the RRE.

Overreporting of Claims
Lastly, a topic raised by one participant on the town hall was potential overreporting of claims in the Section 111 process. The caller indicated that the overreporting was due to an abundance of caution and potentially conflicting advice from vendors, and that it mainly occurred with no-fault and liability claims.

While the idea of missing claims that should be reported to CMS can be frightening, it is important to realize that the guidance and thresholds published by CMS must be maintained as closely as possible. Underreporting is bad, but so is overreporting. As the caller stated, overreporting was creating issues with conditional payments, which led to resources being wasted on unnecessary tasks.

But once again, we are waiting for CMS to define more clearly how they will identify and fine for situations involving discrepancies between Section 111 data and information discovered during the recovery process. Could CMS fine an RRE for overreporting a claim, which should never have been reported, once it causes a conditional payment? Regardless of the answer, organizations can avoid the issue by following established guidelines and seeking proper advice when uncertain of the right choices.

If you have questions or concerns, contact us today and we can help simplify the complexities of Section 111 Reporting and get you back on the path to success.