Franco Signor

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Franco Signor

• Section 111 of the Medicare, Medicaid and SCHIP
  Extension Act of 2007
• Bennett L. Pugh
• Franco Signor
• 1618 Montgomery Hwy. Suite 104 278
• [phone]
• www.francosignor.com

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Franco Signor

• Law states
• Beginning July 1, 2009, liability insurance
  including self insurance, no-fault insurance, and
  workers compensation laws and plans must report
  claims involving a Medicare beneficiary to
  Medicare when the claim is resolved (or
  partially resolved) through a settlement,
  judgment, award, or other payment on or after
  July 1, 2009.
• Must also report on all claims for which the
  responsible reporting entity still has
  responsibility for ongoing payments for medical
  services as of July1, 2009, such as open
  medicals in workers compensation claims.
• Dates have been revised.

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Franco Signor

• Section 111 Notification Requirements
• To assist Medicare with recovery of CPCs and to
  keep Medicare from paying when a primary payer
  exists (or arguably exists), the law now imposes
  obligation to notify Medicare of primary payer
  situations starting in 2009.

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Franco Signor

• Who is the RRE?
• According to CMS . . .
• For re-insurance, stop loss insurance, excess
  insurance, umbrella insurance, guaranty funds,
  patient compensation funds, etc. which have
  responsibility beyond a certain limit, the key in
  determining whether or not reporting for 42 U.S.C
  1395y(b)(8) is required for these situations is
  whether or not the payment is to the injured
  claimant/representative of the injured claimant
  vs. payment to the self-insured entity to
  reimburse the self-insured entity. Where payment
  is being made to reimburse the self-insured
  entity, the self-insured entity is the RRE for
  purposes a settlement, judgment, award, or other
  payment to or on behalf of the injured party and
  no reporting is required by the insurer
  reimbursing the self-insured entity.

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Franco Signor

• Deductibles
• Where the self-insurance in question is a
  deductible, and the insurer is responsible for
  Section 111 reporting with respect to the policy,
  it is responsible for reporting both the
  deductible and any amount in excess of the
  deductible.
• The total of both the deductible and any amount
  in excess of the deductible should be reported.
• If an insured entity engages in a business,
  trade, or profession and acts without recourse to
  its insurance, it is responsible for Section 111
  reporting with respect to those actions.

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Franco Signor

• Reporting in the Corporate Structure
• An entity may not register as a RRE for a sibling
  in its corporate structure.
• An entity may register as a RRE for any direct
  subsidiary in its corporate structure.
• A parent entity may register as a RRE for any
  subsidiary in its corporate structure regardless
  of whether or not the parent would otherwise
  qualify as a RRE.
• For reporting purposes, a captive is considered a
  subsidiary of a parent entity and a sibling of
  any other subsidiary.

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Franco Signor

• Which Claims Must be Reported
• Any claim involving Medicare beneficiaries in
  which medicals are claimed and/or released in a
  settlement, judgment, award, or other payment
  resolving (or partially resolving) the claim.
• Subject to timelines, exceptions, and lookback
  provisions.

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Franco Signor

• ORM
• Claims with Ongoing Responsibility for Medical
  Payments (ORM) must be reported.
• RRE either accepted responsibility but hasnt yet
  made a payment.
• RRE has made at lease one payment to the claimant
  or on behalf of the claimant.

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Franco Signor

• Total Payment Obligation to the Claimant (TPOC)
• Defined as a one-time payment, as in a
  settlement, judgment, award, or other payment as
  intended to resolve/partially resolve a claim.
• Typically applicable in liability cases
• Liability insurance (including self-insurance)
  claim reports where the TPOC date is prior to
  October 1, 2011 with no ORM involvement do not
  have to be reported.

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Franco Signor

• Redundancy
• On claims with multiple defendants, ALL RREs
  involved in a settlement remain responsible to
  also report the claim to Medicare.
• Records must be submitted on beneficiary by
  beneficiary basis, by type of insurance, by
  policy number, by RRE, etc. Therefore, an RRE
  may submit more than one record for a particular
  individual in a particular quarters submission
  window.

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Franco Signor

• Date of Incident
• In workers comp., the date of incident does not
  matter. If a claim is pending on or after January
  1, 2010, it must be reported if appropriate.
• In liability context, if the date of incident is
  prior to December 5, 1980, reporting is not
  required on such claims even if such claim is
  settled on or after October 1, 2011.
• For exposure claims, if any exposure was
  subsequent to December 5, 1980, claim must be
  reported if not settled prior to October 1, 2011.

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Franco Signor

• Interim Reporting Thresholds
• For no-fault insurance there is no de minimus
  dollar threshold.
• For liability insurance there is no de minimus
  dollar threshold for reporting claims with ORM.
• For workers compensation file submissions, only
  claims with ORM which meet all of the following
  are excluded from reporting
• Medicals only
• Lost time of no more than seven calendar days
• All payments made directly to the provider
• Total payment does not exceed 750.00

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Franco Signor
Mandatory Thresholds for Workers Compensation
TPOCs
Total TPOC Amount TPOC Date On or After Reporting Required in the Quarter Beginning
TPOCs over 5,000 October 1, 2010 January 1, 2011
TPOCs over 2,000 October 1, 2013 January 1, 2014
TPOCs over 300 October 1, 2014 January 1, 2015
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Franco Signor
Mandatory Thresholds for Liability TPOCs
Total TPOC Amount TPOC Date On or After Reporting Required in the Quarter Beginning
TPOCs over 25,000 July 1, 2012 October 1,2012
TPOCs over 5,000 October 1, 2012 January 1, 2013
TPOCs over 2,000 October 1, 2013 January 1, 2014
TPOCs over 300 October 1, 2014 January 1, 2015
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Franco Signor

• Claims That DO NOT Have To Be Reported
• Claims in which
• A judgment or defense verdict is rendered
  concluding that no money is owed.
• No claim was made for medical expenses, i.e.,
  liability case with property damage on with no
  release of medicals.
• Be careful with general releases!
• There is no settlement, judgment, award, or other
  payment (including assumption of ORM).
• The only payment was a onetime payment for a
  defense evaluation from a provider or physician.

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Franco Signor

• Direct Data Entry (DDE)
• DDE option will be available to RREs who will
  only submit 500 or fewer claims per year.
• RREs must register to utilize the DDE option.
• Claim records will be submitted one report at a
  time.
• Separate query function will not be offered.

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Franco Signor

• Query Function
• A RRE or its Agent my query Medicare once a
  month, per RRE ID, to determine whether
  individuals are current Medicare beneficiaries.
• Must provide name, social security number, date
  of birth, and gender.
• CMS will send a response file indicating if the
  data provided matched a Medicare beneficiary.

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Franco Signor

• Beneficiary Lookup
• Users of the Section 111 COB website can submit
  online requests, in addition to query file
  submissions, to find out if the individual can be
  matched to a Medicare beneficiary.
• Beneficiary Lookup is not available to RREs
  using the DDE submission method.
• Limited to 100 requests per month, per RRE ID.

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Franco Signor

• Penalties for Failure to Comply
• Plans failing to provide notification to Medicare
  are subject to civil penalty of 1,000.00 per
  day, per claimant.
• There are no safe harbors. All plans are expected
  to comply.

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Franco Signor

• Notification Requirements will ensure Medicare
  does not pay when another entity is, even
  arguably, responsible.
• Will also enable Medicare to more easily recover
  conditional payments from primary payers.
• Expected to save Medicare over 1 billion between
  2010 and 2017.

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Franco Signor

• CMS Memo 2/24/2010
• In general, a Section 111 NGHP RRE will be
  compliant with its Section 111 reporting
  requirements if it registers for reporting, and
  once registered, the RRE engages in data exchange
  testing, and once testing is completed the RRE
  begins and continues with regular Section 111
  production data exchanges. The RRE will then be
  participating in the Section 111 process in the
  manner prescribed by CMS.

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Franco Signor

• The User Guide revised July 3, 2012 contains
  important information regarding Section 111.
• Additional information can also be found at
  Medicares Reporting website
• http//www.cms.hhs.gov/MandatoryInsRep/
• Specific Questions may be emailed to CMS at
• PL10-173SEC111-comments_at_cms.hhs.gov

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Franco Signor

• Questions?

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Franco Signor

• Bennett L. Pugh
• Franco Signor
• 1618 Montgomery Hwy. Suite 104 278
• [phone]
• ben.pugh_at_francosignor.com

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Franco Signor

• Medicare IVIG Access Strengthening Medicare
  Repaying  Taxpayer Act of 2012
•  Became law on 1/10/13
•  Access to Intravenous Immune Globuline
•  Contains 5 Sections that deal with Medicare
  Compliance

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Franco Signor

• Section 201 Conditional Payment Information
•  Effective 9 months after passed into law.
•  This is the deadline for CMS to adopt final
  regulations to implement
•  Allows parties to obtain CPC information before
  settlement in a timely manner
•  Applies to WC and GL claims

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Franco Signor

• Demand Letter
•  Parties may request a demand letter from
  Medicare that is good for a period of time before
  settlement
•  Requires CMS to be provided notice within 120
  days of an expected or reasonably expected date
  of settlement
•  CMS has 65 days to provide demand letter but can
  extend it another 30 days
•  After appropriate period has elapsed, parties
  can retrieve CPC info from website and relay on
  it
•  Settlement must occur within 120 days of notice
  and 3 days from download from website

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Franco Signor

• Jurisdiction
• If elected, the Secretaries determination is
  final
• If procedure not followed, default to previous
  method
• Right of appeal provided to primary payer but not
  Medicare.  Beneficiary must be given notice.
• Federal jurisdiction created 
• No impact on MSAs

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Franco Signor

• Section 202 Reporting Thresholds 
• Effective 1/1/14 
• Applies only to liability claims (expected
  recovery is less than cost to recover)
• Excludes ingestion, implantation and exposure
  cases
• Annual threshold calculated by Secretary of HHS
  published by 11/15
• No obligation to repay Medicare or report if
  claim falls below annual threshold.
• CMS is to report to Congress on thresholds for WC
  and No Fault

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Franco Signor

• Section 203  Reporting Under Section 111 
• Effective 1/10/13
• Amended to provide up to 1,000 per day per
  claim, giving Medicare discretion
• Requires Medicare to solicit proposals for safe
  harbor situations within 60 days
• Requires Medicare to propose final safe harbors
  for good faith efforts when beneficiary cannot be
  determined
• No deadline for final safe harbor proposals

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Franco Signor

• Section 204 Use of SSN in Reporting
• Effective 18 months after enactment
• Secretary can request a one year extension on
  application to Congress
• Allows RREs to report without using the SSN or
  HCIN
• Mitigates against potential state law privacy
  claims

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Franco Signor

• Section 205  Statute of Limitations
• Effective 6 months after enactment 
• Creates a 3 year statute of limitations on CPC
  and Section 111 reporting from settlement,
  judgment, award or other payment
• To trigger the protection, the claim must be
  electronically reported