Gina Cox No Comments

Use Data to Improve Medicare Claims ReportingThe advent of new and improved technology for data collection is continually improving efficiencies for P&C Insurers. However, you still have to know how to use and analyze this data to improve Medicare reporting and compliance.

Here are three significant improvements that better data analysis provides P&C insurers:

1. To Locate ALL Medicare Beneficiaries

Most companies automatically query the Medicare database to confirm whether or not their claims involve a Medicare beneficiary. For many carriers their in-house or third party software will check the age of a claimant and identify the claims involving people over the age of 65 to confirm Medicare enrollment. However, several eligibility qualifications are not age-based, and these are sometimes missed.

U.S. citizens under the age of 65 can receive Medicare if one or more of the following applies to them:

  • They have been entitled to a minimum of 24 months of Social Security Disability insurance benefits.
  • They receive a disability pension from the Railroad Retirement Board.
  • They are diagnosed with amyotrophic lateral sclerosis (ALS or Lou Gherig’s Disease).
  • They are diagnosed with permanent kidney failure requiring regular dialysis or a transplant.

Factors such as work history (for them or their spouse) and payment of social security and/or Medicare taxes can also determine whether or not these individuals receive Medicare coverage. Also, the claimant must be a Medicare beneficiary “at the time of the settlement,” not necessarily at the time of the claim being originated. So, if a claim takes a while to settle, their status may change, which can allow some to fall through the cracks.

With access to all of the appropriate data, along with the ability to digest and analyze it, a P&C insurer can confirm that every single Medicare beneficiary among their claimants is properly identified.

2. To Locate ALL Medicare Claims

It’s not uncommon for insurers to “cherry-pick” their biggest Medicare-related claims for compliance review and closure, while allowing lower-value claims to slide by under the radar despite having reported them under Section 111. Unfortunately, they often do this on the advice of vendors or attorneys who make their livings based on the size of the settlements they achieve. These people have a stake in making sure they’re not spending time on smaller claims.

But in reality, every single Medicare claim presents the potential for disproportionately large penalties and recovery charges if not handled properly. The vendors who recommend an insurer cherry-pick claims they process will not be liable for those charges. The insurer will be.

In the course of handling the full scope of Medicare compliance claims for our clients, we routinely inspect all of the client’s claims to ensure that all Medicare beneficiaries are properly identified. We also go through all of those claims to ensure that every claim is processed properly so that our clients are 100% Medicare compliant.

For more details on why cherry-picking is a bad idea from a compliance standpoint, read our blog post on that topic.

3. To Avoid Penalties

Section 111 Reporting specifies that settlements, judgments, awards or other payment(s) made to a Medicare beneficiary as a result of a personal injury claim, must be reported to Medicare. The penalty for failure to do so can be up to $1,000/day per claim.

The appropriate data collection and reporting system ensures secure data transmission and keeps an historical record of correspondence with Medicare to create a Section 111 Reporting audit trail. “Getting querying right” means (1) identifying all claims involving personal injury, then (2) ensuring all the data required to query Medicare’s database has been sourced for each claim.

Properly collecting and analyzing data related to Medicare claims can mitigate your risk and save millions of dollars. Get started today and let us bring the power of data to your compliance efforts.


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