Medicare Risk Review
Internal Medicare claims management is time consuming and error-prone because the Federal regulations are complex and continuously changing. It is virtually impossible for individual claim adjusters to stay on top of on-going changes, but non-compliance can result in financial penalties and negative publicity.
What is Your Compliance Status?
For most P&C insurers, 10% – 15% of personal injury claims involve a Medicare beneficiary. Because the number of such claims is relatively small, they are typically managed at the claim adjuster desk. Many P&C insurers have not created systems for managing the process and tracking their overall compliance status, including:
- Identifying all Medicare beneficiaries (18% are under age 65);
- Complying with Section 111 Reporting obligations;
- Managing Conditional Payment reimbursements and rebuttals;
- Creating Medicare Set-Asides (MSAs) or alternative options;
- Securing Medicare beneficiary file closure documents.
What to Expect from Flagship’s MRR
Flagship’s proprietary Medicare Risk Review (MRR) eliminates the unknowns and provides an analysis of insurer’s Medicare compliance status, including processing procedures, potential Conditional Payment rebuttal savings, plus any non-compliance issues and/or penalty exposure. Additionally, Flagship identifies Medicare training needs for claim professionals that include performance measures and best practices for accelerating settlements, minimizing litigation and avoiding penalties.
Flagship is keenly aware of the most common, as well as the infrequent, non-compliance issues. We understand how to protect clients’ financial resources by minimizing reimbursements, mitigating penalties, ensuring compliance and accelerating settlement. A Medicare Risk Review removes the uncertainties surrounding Medicare compliance, and completes the steps required to close a Medicare file and create a valid audit trail. At the conclusion of an MRR, Flagship provides client with a comprehensive Executive Summary showing audit findings, solutions and recommended actions.
Components of an MRR include the following:
- Claim File Analysis
Review cross-section of Medicare claims including high dollar, no fault, litigated, settled and open claims.
- Claims Staff Interviews
Interviews with vertical slice of Claims Department, from managers and supervisors, to front-line claim adjusters.
- Medicare Essentials Training
Brief, but comprehensive, training session for claim professionals. Provides perspective on, and increases sensitivity to, the importance of accurate and timely Medicare claims processing.
- Florida Federal District Court Concludes Medical Providers Are Not Subject to Double Damages Under MSP Act Private Cause of Action (3/15/2018) - Rafael Gonzalez, Esq. President, Flagship Services Group On March 2, 2018, the United States District Court for the Middle District of Florida, Orlando Division, published its opinion on MSPA Claims 1, LLC v. Halifax Health, Inc., in which the court found that a private right of action under the Medicare Secondary Payer Act, 42 U.S.C. […]
- New Work Comp MSA Review Contractor Starts 3/19/18; No Expected Changes and No News on Liability MSAs (3/14/2018) - Rafael Gonzalez, Esq. President, Flagship Services Group It has been a long time coming, two years to be exact. After the Centers for Medicare and Medicaid Services (CMS) announced their anticipated release of a solicitation for the Workers’ Compensation Review Contractor (WCRC) in 2016 and 2017 and further announced it was continuing to consider expanding […]
- NCCI Publishes 2018 Update on Medicare Set Asides and Workers Compensation (2/12/2018) - Rafael Gonzalez, Esq. President, Flagship Services Group On February 8, 2018, the National Council on Compensation Insurance (NCCI) published its MEDICARE SET-ASIDES AND WORKERS COMPENSATION— 2018 UPDATE (study), written by Nedžad Arnautović. The study can be found at https://www.ncci.com/Articles/Documents/II_MSA-WC-Study.pdf What follows is a verbatim rendition of the facts, analysis, findings and conclusions found in the […]