On July 1, 2009, CMS will begin imposing new mandatory reporting requirements on liability insurance, no-fault insurance and workers' compensation, under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). Businesses that self-insure for these types of insurance (in some cases, payment of the deductible portion of insurance can be considered "self-insurance"), as well as insurance companies that write such insurance, are impacted. Failure to comply with the Section 111 mandatory reporting requirements can result in civil penalties of $1,000 per day for each day of non-compliance per claimant.
Under federal law, Medicare is the secondary payer for Medicare beneficiaries who also have group health plan (GHP) coverage, as well as for Medicare beneficiaries who receive settlements, judgments, awards or other payment from liability insurance (including self-insurance), no-fault insurance, or workers' compensation (non-group health plans or NGHPs). The purpose of the Section 111 mandatory reporting is to bring to CMS's attention instances when Medicare beneficiaries receive payments that relieve CMS of its obligation to cover medical costs. (Separate reporting requirements for GHPs became effective on Jan. 1, 2009).
The actual Section 111 reporting for each plan must be done electronically by the plan's "Responsible Reporting Entity" (RRE). Determining who the RRE is can be complex, particularly in the case of self-insurance, re-insurance, stop loss insurance, high deductible plans, excess insurance, umbrella insurance, guaranty funds, patient compensation funds, and where there are multiple defendants involved in a settlement.
RREs for non-group health plans must register with CMS's Coordination of Benefits Contractor (COBC) via the COBC's secure website and test the data submission process between May 1, 2009 and June 30, 2009, unless the RRE will have nothing to report. However, RREs who do not register initially because they have no expectation of having claims to report must register in time to allow a full quarter for testing if they have future situations where they have a reasonable expectation of having to report. An RRE may contract with an entity such as a data service company or consulting company to act as an agent for reporting purposes, but initial registration for reporting and file submission with the COBC must be completed by the RRE, and the RRE remains solely responsible and accountable for complying with the Section 111 requirements and the accuracy of the data reported.
After initial registration and testing, RREs will be assigned a seven-day timeframe during which they are to submit files to CMS each calendar quarter. In their initial report (to be made in the required seven day timeframe during the fourth quarter of 2009), RREs are required to submit files containing information for all NGHP claims involving a Medicare beneficiary as the injured party where the settlement, judgment, award or other payment date is July 1, 2009 or subsequent, or the RRE has ongoing responsibility for medical service payments as of July 1, 2009. Subsequent quarterly file submissions are to contain only new or changed claim information concerning Medicare beneficiaries.
The information that must be collected and reported by RREs includes, among other data elements: identifying information concerning the injured party; information regarding the primary plan and policy-holder and whether or not self-insured; information concerning the date and location of the injury; information concerning the resolution of the claim, including whether or not the claim was contested and whether or not there is ongoing responsibility; identifying information concerning the injured party's attorney; additional information about the nature and cause of the injury, including ICD-9 codes and body part(s) involved; and settlement information, including date, amount and method of funding.
In addition, RREs must implement a procedure in their claims review process to determine whether an injured party is a Medicare beneficiary. CMS is establishing a "query access system" to assist RREs in making this determination.
Over the past several months, CMS has held a series of Town Hall Teleconferences and published a number of updates and guides to help clarify the mandatory reporting requirements for both GHPs and NGHPs. The teleconference transcripts, as well as the updates and guides are available on CMS's Section 111 Mandatory Reporting web site.
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