Gina Cox No Comments

In the past, the two main components of Medicare compliance – reporting and recovery – were separate from one another. While they’ve always been directly related, they have not actually connected in any meaningful way.

To legally remain in compliance, every P&C insurance company is responsible for both Reporting and Recovery. Medicare expects all Responsible Reporting Entities to:

  • Accurately report all applicable claims through Section 111 reporting to determine exactly how much is owed to Medicare, and pay them back.

However, practically speaking, the recovery side got the emphasis. Section 111 reporting was viewed as a “necessary evil” that could and should be handled as quickly and simply as possible, often through automated systems with little or no governance. Most companies spent the time and money to develop a process to comply with Section 111 guidelines. Because the reporting side never “connected” to the recovery side, many companies have continued to rely on the rules and processes they set up in 2010.

But things have since changed and companies cannot just assume rely on old processes.

What has changed with Section 111 reporting?

The introduction of the Commercial Repayment Center (CRC) in October 2015 marked a turning point in how Medicare handles both reporting and recovery, specifically when it comes to no-fault claims.

Previously, your Section 111 reporting had little relevance or impact on recovery. As of October 2015, your Section 111 reporting has a direct and immediate impact on the recovery side of the equation.

Flagship_196_Crop.jpgSpecifically, any time a responsible reporting entity (RRE) assumes or terminates ongoing responsibility for medicals (ORM), Medicare shares that Section 111 report with the Commercial Repayment Center (CRC) the entity responsible for Recovery on No-Fault and Workers Compensation claims. They will immediately query their records for any bills they’ve already paid that they believe are related to the claim and issue a conditional payment notice (CPN) based on that information.

Why does Section 111 reporting matter more now?

With the introduction of the CRC, there is little room for error. Accuracy and timeliness are more important than ever.

Learn more about Flagship compliance services.

Whereas the insurance companies used to be in control of the Medicare compliance timeline and could generally obtain complete and accurate information from Medicare prior to settlement – regardless of what was initially reported – that’s no longer the case. Now, the report itself starts the recovery process, including a ticking clock.

Suddenly, the accuracy of that initial report is far more important than it once was. 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 the clock ticking, 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. In addition to facing fines or penalties for late reporting, this can also delay the closure or settlement of your claim.

Finally, reporting an accurate termination date through Section 111 is now the only means of closing out a no-fault claim from Medicare’s perspective. If this does not occur, there’s a chance the RRE can get additional CPNs down the road, regardless of the fact that benefits have been exhausted, settlement has been reached, or the statute has expired.

A simple solution

The simplest solution to this potentially disruptive and expensive change in Medicare compliance procedure is to allow Flagship Services Group to handle both the reporting and the recovery process for your company.

To review your Section 111 process and determine it’s effectiveness, contact Flagship Services Group today.



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