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.
- Ghostbusters (11/1/2019) - In 1984, Ivy League trained parapsychologists Venkman, Stantz, and Spengler started a ghost-catching business in New York City, despite implausible research, and eventually were welcomed as heroes by saving the city from the paranormal disguised as giant marshmallow man Stay Puft. Only in the movies! But, we can use this ghoulish time of the year to serve as a reminder: Don’t let MSP enforcement claims by Medicare Part C Advantage Plans sneak up to shock and detract your standard claims operating procedures. Identifying and resolving these repayment claims may be just as important a part to your overall MSP compliance strategy as similar claims by traditional Medicare Parts A and B.
- How far is too far when negotiating Medicare release terms? (10/7/2019) - At the recent NAMSAP Educational Conference in Baltimore, during a breakout panel discussion on “Leveraging Settlement with Medicare Set-Asides in Mediation”, a rather strident concern was raised with respect to the reasonable scope of terms in a settlement release irrespective of the type of primary plan covering the loss. Specifically, attendees questioned whether Medicare eligible individuals could or to what extent may release their claim or claims in the future to these public health and welfare insurance benefits while negotiating compromise settlement provisions under liability, no-fault or workers compensation plan.
- Treasury Trove (9/17/2019) - Medicare is paid for through two Trust Fund accounts—Hospital Insurance and Supplementary Medical Insurance—held by the United States Department of Treasury, How Is Medicare Funded. In 2018, over 60 million people were covered by Medicare with over $731 billion in total expenditures from the Trust Funds Facts on Medicare Spending and Financing. Further, CMS reports validating $493.68 million in recoverable mistaken conditional payments, while returning $98.68 million dollars to the Medicare Trust Funds in 2018 as a direct result of its recovery program activities, on top of $131.78 million in 2017, MSPRC Commercial Repayment Center in Fiscal Year 2018. Collection activity by the United States Department of Treasury (DOT) on Medicare conditional payments is reportedly increasing in 2019, plus, over the past 15 months, the United States Department of Justice reached six-figure settlements with two Plaintiff’s law firms for failure to repay Medicare conditional payments.