Katie A. Fox, MSCC – October 21, 2011

The much awaited Version 3.2 of the User Guide was released on August, 17, 2011. The User Guide outlines several changes, but hidden in section 11.8 is a process to manually terminate the ORM status between Section 111 claim detail electronic submissions.  Throughout the industry the subsequent memorandums have gained much publicity, potentially overshadowing the availability of the Manual ORM termination process. The process is outlined in Section 11.8 of the User Guide, and would apply to any claim that has ongoing responsibility to pay medical benefits (WC, No-fault, GL Medpay).

The Worker’s Compensation industry has expressed concern about charges incurred after the Plan had terminated. This concern arises when several events take place. Examples of these ORM Termination events are Full Recovery by the authorized treating physician, statutory termination of responsibility, or claim denial after a statutory investigation period.

If the Medicare beneficiary was treating under a state WC program, and was seeking care from the authorized treating physician, who released the Medicare beneficiary to return to work and from care on 2/15/2011, but the reporting window was not until the 11th week in the quarter, there is a possibility that Medicare may receive medical bills for services outside the worker’s compensation plan. These charges could either be denied or paid as a conditional payment by Medicare, when in actuality the beneficiary was seeking care outside the coverage of the worker’s compensation plan.

The same concern could arise if the worker’s compensation Judge awards a termination of coverage,  based on the applicable state statutory guidelines. Many jurisdictions have grounds for termination of care, regardless of the state requirements the outcome would be the same. The Medicare beneficiary may have continued care after the date that the Judge found the Medicare beneficiary’s medical coverage under the workers’ compensation plan to have concluded. It is not uncommon for these injured employees to seek care outside of the workers’ compensation system following such a judicial determination.  This is another example of when a manual ORM Termination would be appropriate and most prudent to manage one’s Medicare Secondary Payer risk.

Franco Signor LLC has designed a product to assist their clients in the manual termination process. We feel it is cost effective to utilize the Manual ORM Termination process over working with the MSPRC subsequently to attempt to remove the unrelated charges following the date the ORM Terminated. The cost in time and financial exposure greatly outweigh this simple manual solution. Our goal is to keep our clients ahead of the curve of Medicare Compliance, while focusing on cost effective solutions.

Franco Signor LLC will have several representatives at the National Worker’s Compensation & Disability Conference in Las Vegas, NV held on November 9-11, 2011. Please contact Katie A. Fox, MSCC at 716-877-4677 extension 121 to set up an individual meeting or email her at katie.fox@francosignor.com to discuss how Franco Signor LLC can assist you.


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