Gina Cox No Comments

tumblr_myebwtELvb1st5lhmo1_1280Every few months a new change – major or minor – rocks the Medicare compliance industry, leaving many insurers scrambling to keep up. These constant changes put a strain on internal training departments where Medicare Compliance is handled in-house as they need to continually update the claims adjusters on the newest guidelines.

In some cases, changes even require adjustments to the software or hardware used in reporting and processing Medicare-related claims, which can further create financial and time resource difficulties.

For example, just a few months ago (on October 1, 2014) the minimum threshold for liability claims that must be reported under Section 111 reset from $2,000 to $1,000. Immediately, a change was needed in all automated or manual claim-identification procedures to ensure all the claims that fell between those two thresholds were going to be captured accurately for reporting purposes. Otherwise, a penalty of $1,000 per day per claim could be levied against the carrier.

In 2015, changes are expected to continue at the same pace. We expect a few significant changes to come along with a number of smaller adjustments, but every single one can mean potential risk to any primary payer who falls out of the loop.

Greater reporting volume

As noted above, the minimum threshold for liability claims dropped to $1,000 and the threshold for Workers’ Compensation claims dropped from $2,000 to $300. Overall, there are going to be far more claims that require Section 111 reporting this year than last year.

New CJ07 error code

Since claims can still be submitted now that occurred prior to the change, companies need to be very careful to apply the proper thresholds to claims depending on their TPOC dates. Otherwise, the claims will generate a CJ07 error code and will need to be removed or adjusted accordingly. Likewise, any claims not reported due to this oversight will be liable for fines.

Changes to the filing software fields

On 1/5/15, CMS began accepting reports with only the last five digits of a claimant’s social security number when the RRE is unable to obtain the full SSN for some reason. In this case, the RRE must also provide the claimant’s first initial, last name, gender, and date of birth.

Likewise, as of 4/6/15, the naming conventions for Claim Response, TIN Response, and Query Response files is changing to better ensure that each file has a unique identifier.

Beginning on 7/13/15, new fields will be included on the TIN Reference File and DDE claim submissions to allow RREs to provide the name and contact information for a recovery agent that is assisting them with recovery related work (not just Claim Input File submissions.)

As of 10/1/15, claims filed will require the ICD-10 diagnosis codes be included in order to be considered successfully reported.

Staying on top of changes

Of course, there are many other changes we can reasonably expect to occur, although official announcements have not been made. Among these, perhaps the biggest change to affect P&C insurers in a decade, is the upcoming widespread installation of Recovery Audit Contractors (RACs) along with all the implications of their efforts to identify and recover any and all money owed to Medicare from conditional payments.

Here at Flagship, staying on top of all these changes is part of our daily life. Medicare Compliance in all its intricacy is all we do. And we do it very well.

If you’re concerned that your organization may not be staying on top of compliance regulation changes as well as you should, or if it’s just becoming too difficult to do so perfectly, contact us to discuss what we can do to help.

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