Over the past two months, we’ve explored Section 111 at a high level. Now let’s dive into the specific components of Section 111 reporting. Medicare reporting is effectively divided into two basic parts: the initial eligibility query process and the subsequent claim reporting (ORM and TPOC, respectively, which we’ll discuss over the next few months). In this article, we’ll take a look at the Medicare eligibility query process. To understand how the query process fits with Section 111’s purpose and process, we need look no further than the user guide itself.
Responsible reporting entities (RREs) are required first to identify Medicare beneficiaries and then report certain data to Medicare in the form and manner specified by the Secretary of Health and Human Services. Before Section 111 reporting, there were no electronic means to identify Medicare beneficiaries. So, how does an RRE determine which claimants are eligible for Medicare without relying on a claimant to self-identify?
Medicare’s answer is the query process.
The query process is a gift from Medicare. Each RRE can send Medicare a list of claimants monthly, and Medicare will tell you which claimants are Medicare beneficiaries. Using the query process is simple, and you need only the data that your claims staff already routinely collects, such as claimant’s name, SSN, DOB, and gender. After this information is transmitted, Medicare sends responses quickly, and RREs can identify which claims involve Medicare beneficiaries. Once you’ve identified a Medicare beneficiary, you’ve satisfied the first part of Section 111 reporting.
The query process can also help an RRE in other aspects of MSP compliance. First, when you discover you have a Medicare beneficiary, you know it’s possible that Medicare has made payments related to the underlying accident. The query process provides you a road map that identifies which cases may have conditional payments.
For claims that require future medical considerations post-settlement, the query process can help you determine a subset of claimants for whom you may want to consider using a Medicare Set-Aside (MSA) to help facilitate settlement.
There’s no question that the query process is a critical tool. The clear benefit is that query results will tell each RRE which claimants are eligible for Medicare. But looking beyond their obvious use, you can also use query results to give you a strategic advantage.