Your Section 111 reporting program may seem clear-cut, but it can mean risky business if your team isn’t prepared to avoid the pitfalls of common compliance mistakes.
The primary objective of Section 111 reporting is to alert Medicare to bodily injury claims involving Medicare beneficiaries. This sets the course for Medicare to track claim-related payments and, ultimately, exercise its right to recover payments it may have made.
While these objectives seem straightforward, simple errors in reporting often end up snowballing if not corrected promptly. So it’s important to train claims handlers proactively to properly report ongoing responsibility for medicals (ORM) and TPOC settlements (total payment obligation to claimant). Mastering the following five common areas of confusion can help.
1. Report the proper ICD codes.
The ICD codes reported to Medicare set in motion many elements of Medicare Secondary Payer (MSP) compliance. These codes allow Medicare to track which medical services claims should have been paid first by the responsible reporting entity (RRE). If reported correctly, many headaches in dealing with conditional payments and coordination/denial of benefits issues can be prevented. Unfortunately, they’re often omitted when they’re not readily available or the injury is unclear.
- Send at least one valid diagnosis code for each injury in a claim. If there’s more than one injury, the reported codes should be either all ICD-9 or all ICD-10 codes, not both. If the date of incident is on or after October 1, 2015, only ICD-10 codes are accepted.
- Choose the most specific code available that covers the claimed injury.
- Avoid including ICD codes found in medical records for unrelated treatment.
2. Don't use the "NOINJ" code, unless it's specifically warranted.
When there is no known ICD code associated with the claimed injury, the common inclination is to use the NOINJ (no injury) code. However, this code has limited application in Medicare reporting. If the NOINJ code is used in any other context, it will be rejected.
- The NOINJ code is only appropriate when reporting a liability claim for loss of consortium, errors and omissions, directors and officers liability, or a claim resulting from a wrongful action related to employment status.
3. Don't group the reporting for different insurance types under one claim.
A single claim can often have many components relating to different coverage types, and when handled by the same insurer, it’s tempting to report them together. But each coverage type—first-party, (that is, no-fault/PIP/med pay) or third-party (that is, general liability)—will require a different coordination of benefits function. Therefore, conditional payments would be handled by separate Medicare contractors. Consequently, it’s easier to report them separately.
- Claims with ORM (no-fault/PIP/med pay, workers’ compensation) are handled by the Commercial Repayment Center (CRC).
- When Medicare is seeking reimbursement from the beneficiary as part of a settlement by liability insurance (including self-insurance), no-fault insurance, or workers’ compensation, recoveries are handled by the Benefits Coordination & Recovery Center (BCRC).
4. Don't report all closed claims the same way.
Reporting closed claims involving a Medicare-eligible party can cause many RREs to get tripped up, particularly because the decision to close a claim can be for different reasons internally.
- Always report when a medical claim settles entirely and a lump sum payment (above the appropriate threshold) is made to the claimant (TPOC).
- Once the ORM indicator is set to “Y” (Yes), it must remain that way; it’s not an on/off switch. When a claim with ORM settles and closes (that is, the no-fault policy limits were reached or the time period for benefits expired), enter an ORM termination date to signify when ORM ended.
- When an adjuster decides to close the claim administratively—but ORM is subject to reopening (that is, the claimant retains the ability to submit or apply for payments for additional medicals related to the claim)—Medicare still considers an RRE to have ORM. In this case, termination shouldn’t be entered.
5. Report the correct TPOC date and amount.
TPOC amounts and dates can also cause confusion, so caution is in order.
- It’s important to report the entire payment made to a Medicare-eligible party under a settlement regardless of any other amount to be paid under ORM. Remember, an RRE is not entitled to determine what part of the settlement payment is apportioned for medicals. Therefore, it’s best not to separate medical and nonmedical payments if medicals have been claimed and/or released or if the settlement otherwise has the effect of releasing medicals. In addition, settlements must be reported regardless of whether there was an admission or determination of liability or the resolution was either partial or full.
- If there is an issue of joint and several liability among multiple defendants, each RRE must report the total settlement amount regardless of each party’s contribution.
- If multiple defendants each have separate settlements, each RRE must report that separate settlement amount regardless of which entity issued the payment. All RREs are responsible for their own reporting, and the reports should be cumulative rather than duplicative.
- The TPOC date is the date the payment obligation was established. In other words:
- It’s the date the obligation is signed, if there is a written agreement.
- If the obligation requires court approval, then report the later of the date the obligation is signed or the date of court approval.
- If there is neither, it’s the date the payment is issued.
Improving Your Practices
While Section 111 poses many different challenges, mastering these five areas should put you on the path toward improving Section 111 reporting. Making sure you have a sound reporting program in place is critical because today’s “error” messages could end up tomorrow’s monetary penalties.
ISO Claims Partners stands ready to assist you with our industry-leading Section 111 reporting services, including our state-of-the-art MSP Navigator™ reporting system and our popular Section 111 audit service.