The fact pattern is simple and straightforward: A Medicare beneficiary is involved in a covered occurrence which necessitates an office or emergency room visit. A reasonable and necessary examination is conducted by a physician which results in no diagnosis. For example, your 75-year old father visits your home and, while napping after a lively family meal, rolls off the couch hitting his head, elbow and hip on the hardwood floor. He has pre-existing conditions related to his hip, so, despite crotchety resistance, he is taken to the emergency room to be checked out. After an outpatient examination, including radiological tests of his head, elbow and hip, he is released from the hospital without any symptoms, specific diagnosis or follow up plan. Everyone goes back home thankful he is OK. Your father receives the hospital bill for $5,000 (with no injury and external cause ICD-10 codes). He makes a claim which is covered and paid by your homeowner’s no fault/PIP insurance policy.
Version 5.9 of the NGHP User Guide is available for download here. Summary of version 5.9 updates:
Today’s headlines on Coronavirus in America: cases surging, states reversing re-opening, nearly half adult population is without a job, and data on Medicare nursing home facility cases and deaths. The federal Medicare Hospital Insurance program (Part A) already faces challenges serving an aging population, increasing enrollment, and rising costs with funding overwhelmingly dependent upon tax revenue in the form of income and payroll taxes. In comparison, Medicare Supplementary Insurance and Prescription Drug Programs (Parts B and D essentially providing physician, outpatient, and medication) are financed through beneficiary premiums and general revenues.
Keeping an eye on a few key cases from around the nation during the first half of 2020.
On May 11, 2020, the 47 public comments were published regarding CMS’ proposed rule under MSP for imposing Certain Civil Money Penalties. The comments were submitted by a variety of entities with diverse perspectives from across the country including corporations, underwriters, state insurance funds, third party administrators, health insurance companies, workers compensation insurers, property and casualty associations, responsible reporting entities (RREs), MSP vendors, law offices, risk management organizations, defense attorney organizations, corporate counsel organizations, health and wellness organizations, and integrated delivery and financing systems (IDFS). Many submissions raised similar concerns, so we tapered down those raised by the commentators into 12 major themes and provide key discussion points underscoring each. CMS is expected to assess and reply to these comments as part of its ongoing ruling making process.
We are living through historic times. COVID-19 may result in permanent changes including how and where we normally work; while, during this same period, the Medicare Secondary Payer (MSP) industry may see CMS finalize and publish regulations regarding how and when to calculate and impose civil monetary penalties (CMPs) upon group health plan (GHP) and non-group health plan (NGHP) responsible reporting entities (RREs) which fail to meet reporting obligations.
In this, our final of a three-part series taking a closer look at each of the key pillars in CMS’ new proposed rules for Civil Monetary Penalties (CMP). Our first two parts looked at Failing to Register and Report, Registering and Reporting, and Poor Quality of Reported Data, Poor Quality of Reported Data.
There is a season for every purpose. Are you reporting as required? Is your reporting data accurate? Do the errors matter? What is your error tolerance level today, and what are its historical tendencies? Is your data transparent and timely? When do repayment and reporting intersect? Who can reliably audit your current compliance level to determine whether you even have a reporting issue? How can our current reporting procedure undergo a risk evaluation?
In the first of a three (3) part series, we will take a closer look at each of the key pillars in the new proposed rules, starting with Failing to Register and Report. The final two (2) parts will cover Poor Quality of Reported Data, and Recovery Information Contradicting Reporting.