Introduction: Purpose and Process
I want to take a moment to introduce a new column in our newsletter. Over the next several months, I’ll be preparing a short column with the goal to demystify Section 111 reporting. For those of you who know me, you’ll immediately laugh when I say “short column.” I am a talker — and I want this column to be the starting point of a discussion. Why am I doing this over several columns? At its heart, Section 111 of the MMSEA (Medicare reporting) doesn’t need to be overly complicated. When separated into its smaller parts, Section 111 reporting is fairly easy to understand. I want to distill it down for everyone so that over the next few months, piece by piece, everyone will become an expert on Section 111 (this will make my job a whole lot easier!).
Here’s my gripe: There are so many MSP/Medicare compliance presentations and trainings out there. Good training (which we most certainly provide) offers a comprehensive review of the federal statutes, code of federal regulations, policy, and case law. The landscape is complicated even to the most seasoned of MSP practitioners. The poor presentations are usually those scheduled right after lunch (of which I might also be guilty). But most presentations — even the best of them — discuss complicated material. Don’t get me wrong — this absolutely has its time and place. But I’m aiming for something different here, and I’m confident I can make this material simple.
My point is that for claims professionals (and managers), it might be good to know the legal underpinnings of MSP compliance, but it would be better to know the actual mechanics — the nuts and bolts of how this process works (“why” is nice, “how” is better).
So how is Section 111 easy? Section 111 is easy when you always keep two things in mind: purpose and process. This is the theme I’ll come back to throughout the column. The purpose of Section 111 is to both coordinate benefits for Medicare beneficiaries and help CMS in its recovery of conditional payments (those “super liens” that you all see from the government). When we keep those two points in mind, the other elements fall into place.
In fact, this is a perfect segue into why Section 111 exists in the first place. Those of you who’ve worked with Medicare might agree that CMS “might” need some help figuring out both how to coordinate benefits and also when to assert conditional payment recoveries.
Coordinating benefits is tricky. There are certain situations where Medicare is a primary payer and other situations where Medicare is a secondary payer. Getting this formula right can depend on the nuanced specific facts of a claim. Without Section 111, CMS would be without the proverbial paddle. The entire process would be left to guesswork. Section 111 gives CMS a direct data feed that tells them when they are a primary payer and when they are a secondary payer. That’s the purpose.
The logical next question is, “Well, what does CMS do with this information?” That’s the easy part — conditional payment recoveries. The formula CMS uses for this is straightforward: If CMS makes a medical payment for a Medicare beneficiary and learns that it’s a secondary payer (think Section 111), then the payment made is considered a conditional payment because it was made under the “condition” that it be repaid by the primary payer. That’s the conditional payment “lien” repayment dynamic in a nutshell. That’s the other purpose.
Using “purpose and process” as my framework, over the next few months we’ll demystify the entire Section 111 process from a high level. In the meantime, contact me directly with any ideas and comments. I can be reached at 978-825-8152 or firstname.lastname@example.org. I look forward to this ongoing discussion.
Daniel C. Lindner is the Director of Section 111 Strategy for ISO Claims Partners. Dan has been with ISO Claims Partners for several years, joining the company as the Compliance Manager overseeing one of ISO Claims Partners’ Medicare Conditional Payment investigation and negotiation teams. In this role, Dan is responsible for the management and coordination of a dynamic team with a national clientele. Dan primary focus is always helping his clients effectively navigate Medicare compliance issues. Dan began his career as a Prosecutor for the Massachusetts Division of Professional Licensure, Health Care Fraud Bureau. After moving to the private sector, Dan specialized in Complex Business Litigation, Federal Civil RICO recoveries (for insurance industry clientele), SIU defense, and defense of bad faith claims. With a background in anti-fraud compliance, and anti-money laundering compliance, the decision to join ISO Claims Partners’ Medicare compliance team was a natural fit. Dan is an avid skier, hiker, cyclist and proud father. Dan can be reached at email@example.com or 978-825-8152.