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Medicare Compliance Reporting and Recovery - the Dynamic Duo?If your goal is 100% Medicare Compliance, then Reporting and Recovery need to go hand in hand as the Dynamic Duo of your claims process.

Reporting and Recovery defined

Let’s clarify exactly what “Reporting” and “Recovery” mean in relation to processing insurance claims for Medicare beneficiaries.

Reporting – Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 added Mandatory Insurer Reporting (MIR) requirements with respect to Medicare beneficiaries who receive settlements, judgements, awards or other payments from liability insurance, no-fault insurance and workers compensation. Most P&C carriers are well aware that, as a Responsible Reporting Entity (RRE), they are required to electronically submit a quarterly report to Medicare on every claim involving a Medicare beneficiary. Being compliant with MIR includes submitting accurate information. RREs are not just responsible for getting the details about the claimant right, but are also responsible for reporting the claim with 100% accuracy

Before October 5, 2015, inaccurate reporting had few consequences besides compliance flags and the threat of fines up to $1,000 per day per claim.  However, all of that changed with the introduction of the Commercial Repayment Center (CRC).

Now, the CRC uses the information provided through MIR to determine their Recovery actions. If the RRE provides inaccurate acceptance dates, erroneous ICD-10 codes, or doesn’t terminate ORM correctly, it can lead to costly mistakes. The CRC uses information reported via MIR to filter through the bills Medicare has paid that are potentially related to the claim, so that they can more effectively enforce Medicare Secondary Payer (MSP) regulations and seek reimbursement. Now, more than ever, RRE’s need to make sure that their MIR process is error-free.

Recovery refers to the closely-related second step in the compliance process in which the RRE reimburses Medicare for any and all legitimate conditional payments Medicare has made on the claimant’s behalf. Reporting is merely putting Medicare on notice that the RRE has a financial obligation while recovery is actually meeting that financial obligation.

Why we keep talking about this

If you’ve visited this blog before, you’ve no doubt read about this topic in the past. Until last year, there was no direct correlation between Reporting and Recovery. Now there is. If your Reporting is methodical, accurate and follows all of Medicare’s policies and procedure, your Recovery will be relatively smooth and contain fewer “surprises.” If your Reporting is haphazard or lacks clear rules and processes, it will be reflected in the Conditional Payment Notices (CPNs) and Final Demand Letters (FDLs) you receive. No one likes these types of surprises. Errors in reporting remains a common, dangerous, but repairable problem in many claims processing departments across the country:

Nearly every P&C carrier has established some combination of automated and manual process to query, identify and flag claims involving a Medicare beneficiary, and most have also implemented a process to ensure that each of the flagged claims is accurately reported to Medicare under Section 111 guidelines.

However, many insurance companies do not have a structured process in place to ensure that every one of the claims they’ve reported to Medicare is followed through to the Recovery phase. The Reporting and Recovery processes need to be synchronized and reconciled so that the RRE is following up with recovery on EVERY claim reported. Once those Conditional Payment Notices (CPNs) start arriving, they need to be analyzed and addressed. Most RREs don’t have the knowledge or bandwidth in-house to research each of those claims thoroughly and confirm that the amount Medicare demands is accurate and related to the claim.

Besides receiving CPNs with unrelated charges, RREs may receive CPNs they are not expecting because they closed the claim but have not terminated ORM, and the CRC still has the claim open in their system. This process is rife with opportunities for overbilling and error and highlights the importance of reconciling Reporting and Recovery efforts.

Two sides of the same coin

At Flagship Services Group, we’ve often used the phrase, “distinguishable but inseparable” to describe the relationship between Reporting and Recovery. In other words, they’re two separate processes. Compliance in one area can cause non-compliance in the other.

That’s how you should be viewing the Reporting and Recovery aspects of your company’s compliance with Medicare regulations: two equally important aspects of the same process. If one is out of sync, it could cost you time and money – and increase your risk of non-compliance.

Are your Section 111 reporting process AND your Medicare lien recovery process both up to snuff? If not, or if you’re not sure, we can help. Download our ebook or contact us to learn more about how we protect your financial assets with our committment to Medicare compliance.


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