In practice, Medicare compliance can be very complex. However, Flagship can mitigate your risk, ensure compliance and simply the process.
The first step to 100% compliance is accurate Section 111 Reporting. Every single time a new claim is initiated, the claims adjuster should ask:
- Is the claimant a Medicare beneficiary?
- Has claimant sustained an injury?
- Has or will money change hands?
If the answer to all these questions is “yes,” then you are legally required to report the claim to Medicare via Section 111.
This sounds easy enough, but when you consider that Medicare beneficiaries make up just 15-18% of the average adjuster’s work load, they do not always have a lot of experience or practice with these claims. It’s easy to forget Medicare’s requirements and it’s hard to keep up with all of Medicare’s changes. Let’s break this down and make it simple.
1. Is the claimant a Medicare beneficiary?
Every P&C carrier has a process in place to identify Medicare beneficiaries for the purpose of compliance reporting. No matter how automated or efficient their system is, however, human error can easily creep into the mix and cause problems.
Usually, the process relies on a claim adjuster or other member of the team to check a box or fill out a form indicating the claimant needs to be queried to see if he/she is a Medicare beneficiary. If this step is overlooked as the claim is being investigated and processed, it may never be reported. Whether it is overlooked initially and caught later on, it may require a tremendous amount of backtracking and extra work to resolve and can delay settlement or closure, not to mention that Medicare may flag the RRE’s account for late reports.
This adds time to the process and increases the possibility that the crucial identification step gets forgotten.
2. Has the claimant sustained an injury?
The claims adjuster needs to determine if the claimant has sustained an injury or if the claim is for auto damage, property damage or some other claim. From a compliance perspective, Section 111 reporting is only necessary when a Medicare beneficiary is being reimbursed or receives a settlement for an injury.
This can be complicated when more than one individual is involved in the incident or when there are several exposures involved.
3. Has or will money change hands?
Once again, the answer to this relatively simple question can lead to complicated possibilities.
If a claims adjuster determines that the insurance company does need to cover some portion or all of a Medicare beneficiary’s medical bills in relation to an injury they’ve sustained, as many as three different reports need be filed through Section 111 for that one claim:
- Assuming ORM (ongoing responsibility for medicals)
- Terminating ORM
- Notification of a settlement or TPOC (total payment obligation to claimant)
Every claim in which money changes hands requires at least one of these, and some may require all three. The timing of these reports, the dates used for assuming and terminating ORM, the need for an accurate ICD-10 diagnosis code, and a number of other factors all serve as potential stumbling blocks in the adjuster’s efforts to appropriately report the claim under Section 111.
Maybe it’s not so easy
At the beginning of this post, we noted that Section 111 reporting is basically simple. And, viewed from 30,000 feet, it is.
But simple doesn’t always equate to easy..
In practice, the ins and outs of the reporting and recovery processes, combined with the relatively small number of claims involved, make Medicare compliance a real challenge for most claims adjusters and managers.
Noncompliance can be costly. Flagship Services Group will partner with you from Section 111 reporting through Recovery and Case Closure. We continually monitor and track changes in Medicare’s policies and process and keep our clients up-to-date and compliant. Let us mitigate your risks, reduce your costs and save your claims adjusters time. Contact us to learn more or download our CRC compliance guide below.