We have heard various complaints that Responsible Reporting Entities are receiving Conditional Payment Notices with unrelated charges or that the Commercial Repayment Center (CRC) isn’t closing claims, but how much of this is CMS’ fault and how much blame rests on the claims adjuster and the RRE?
With the advent of the CRC, the accuracy of your Section 111/Mandatory Insurer Reporting (MIR) is more important than ever. The CRC relies on the information that RREs report electronically with no room for human interpretation. If the date of the incident is incorrect, or the ICD-10 code is wrong, it can mean thousands of dollars of unrelated bills being lumped into the no-fault claim. Any one of a dozen or more potential errors on the report can have the same outcome. And, with short timeframes for disputing unrelated charges, RREs have limited time to catch up and resolve any discrepancies quickly in order to avoid paying Medicare more than they rightfully owe.
Likewise, if something is omitted from the Section 111 report – or if no report is made for a particular no-fault claim – Medicare will not begin recovery procedures. Not reporting the acceptance of ORM in a timely manner can also delay the closure or settlement of your claim. There are enough delays in the process without the RRE knowingly or unknowingly causing more.
Here are a few helpful reminders
Report Assumption of ORM correctly
In the MMSEA Section 111 User Guide, CMS states that, “The trigger for reporting ORM is the assumption of ORM by the RRE – when the RRE has made a determination to assume responsibility for ORM or is otherwise required to assume ORM – not when or after the first payment for medicals under ORM has actually been made. Medical payments do not actually have to be paid on the claim for ORM reporting to be required.”
Don’t forget to Terminate ORM appropriately
Reporting will directly affect recovery. Reporting acceptance alerts Medicare that the RRE is accepting responsibilities for bills related to this date. Medicare has the right to continuous recovery from the time of assumption. They will continuously search for bills that Medicare has paid that could be related to the injury. If Medicare has paid bills they believe are related to the injuries sustained, they will send a Conditional Payment Notice (CPN). Medicare will continue to search for bills until ORM is terminated, so it is possible to get multiple CPNs over the life of a claim. If a claims adjuster reports the acceptance of ORM but never gets around to terminating ORM at the appropriate time, Medicare will just assume the claim is still open and will continue to look for bills that they think could be related to the claim. All open claims are fair game for collections. In other words, there is no end to the continuous recovery until ORM is terminated.
Check and double check accepted injuries
What is reported via Section 111 affects the charges that can be assigned to a CPN.
Claims adjusters should not just assume that all of the ICD-10 codes on a hospital or physician’s bill are related to the injury. It’s quite common for patients to discuss their injuries and any ongoing medical issues in the same visit, especially if the visit is with their primary care physician. Be sure to sort out related ICD-10 codes from chronic medical issues such as diabetes, hypertension, etc. Don’t just copy all of the IDC-10 codes on a bill and report them as being related or you will be billed for them.
Correct inaccuracies quickly
If an RRE reported the assumption of ORM on a claim and then finds out at a later date that it shouldn’t have or if a claims adjuster reported inaccurate ICD-10 codes, refer to the Section 111 Guide and update your report and make corrections as soon as possible.
If you’re finding costly errors or unexpected roadblocks popping up throughout the CRC process, let us know. Our Medicare compliance experts are ready to help.