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Medicare Risk Review

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.

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