Section 111 as usual for Workers’ Compensation, No-Fault and Other ORM Cases
Roy Franco
November 16, 2010

By Katie A. Fox, MSCC

Last Friday, the Centers for Medicare & Medicaid Services (CMS) issued an alert extending the mandatory reporting period for Liability cases with a Total Payment Obligation to Claimant (TPOC) only.  We wrote yesterday about the positive effect this would have on the liability industry struggling to get its data systems ready for reporting.   However, the alert also reinforced for all other non-group health plans (NGHP) and reporting types, mandatory reporting remained on schedule for January 1, 2011.  What that means is that Workers’ Compensation TPOC (meeting the reporting thresholds – see alert) and ongoing responsibility for medical (ORM) is not subject to any delay.  The same applies for no-fault ORM and Liability ORM (such as Medical Payments).  Further, if there is  an associated Liability TPOC in a Liability ORM situation, that TPOC is not subject to delay either.  There is still much work to do before January 1, 2011 and for those Responsible Reporting Entities (RREs) there can be no rest in meeting compliance.

What will be helpful from the CMS announcement is the breathing room the Coordination of Benefits Contractor (COBC) Electronic Data Interface (EDI) representatives will now have in working with the RRE.  Now that Liability TPOC is voluntary, the EDI representatives can focus on the back log of issues that appear to have stalled the flow of data between Medicare and the RRE.  This should reduce a great deal of frustration felt by both sides.

Although relief is welcomed by the industry that would have reported Liability TPOC matters on January 1, 2011, here are the situations that claim operations must still prepare for next January.

Workers’ Compensation ORM – The alert did not change the start date when ORM is to be collected.  As of January 1, 2010, operations should have been collecting all cases that were administratively open as of that date that involved a Medicare beneficiary where the case involved an ongoing obligation to pay medical.  Operations was to continue to add to that list any open case, re-opened case or new case where claimant was a Medicare beneficiary and the ORM existed.  It did not matter the date of injury, as Workers’ Compensation was always primary going back to date Medicare became law, July 1, 1965.  The triggers were Medicare beneficiary, obligation to pay medical and case being administratively opened.

CMS did provide for an exception to workers’ compensation ORM which was to end 12/31/2011.  The new alert extended it to 12/31/2012.  All of the following criteria must be met for the RRE to exclude a particular Workers’ Compensation ORM case from reporting.  They are:  1) “Medical Only” claim; 2) Lost time can be no more than allowed by the particular state jurisdiction for claim to remain “Medical Only” or where there is no such requirement, not more than 7 days; and 3) Medical payments has been made directly to the provider; and 4) Total medical payments do not exceed $750.

No-Fault Insurance – Collection of information related to open no-fault claims as of January 1, 2010 was also required.  Again, the date of loss is not as important as when the obligation is assumed.  Matters that were open as of January 1, 2010 are to be evaluated as well as any new and re-opened matters from that date forward.  Also, any open claim where the claimant later becomes a Medicare beneficiary must be evaluated as well.

Medical Payments Coverage – This coverage is usually associated generally the automobile and general liability policy.  If this coverage is implicated and reported as ORM, then any associated liability TPOC is not exempt from reporting under the recent alert.  Put in another way, only Liability TPOC cases with no ORM involvement have been exempted from reporting next year.  All other matters are still subject to reporting.  It is for that reason, that this particular coverage may be the most difficult to implement next year.  Penalties will not be waived for these type of cases and operations need to be careful.

The recent CMS alert, although welcomed, still leaves all of us with a lot of work.  It provides room for CMS and COBC to remove bottlenecks in the system as it will not have to deal with voluminous Liability TPOC data at the same time.  CMS still expects the data, but it will do so in phases.  The first is workers’ compensation, No-Fault Insurance and other ORM cases.