In part two of this article, we explore how to develop a holistic and programmatic approach to Medicare Secondary Payer obligations.
Using Section 111 data to drive the conditional payment process in an automated and self-executing fashion is the foundation to develop a holistic and programmatic approach to Medicare Secondary Payer obligations. Primary payers can appropriate the query response information to identify claims that are ready to initiate the conditional payment process. No longer are query responses merely flags to determine if ORM or TPOC events may be reportable in the future. Instead, this valuable data should be repurposed and used to drive the Medicare conditional payment process.
Through the development of customized data aggregation to identify conditional payment cases from the Section 111 data feed, a system for initiating the conditional payment process can be implemented by way of:
Moreover, existing technology, such as the Medicare Secondary Payer Recovery Portal, can be used once a recovery case is established with the BCRC. The portal has dramatically reduced many of the time-consuming activities associated with processing conditional payments. Strategic use of the portal combined with a programmatic process compounds the benefits.
The underlying goal in developing this programmatic approach is to obtain as close to 100 percent compliance as possible. When operating in an inefficient Medicare compliance environment and attending to claims ad hoc, there is more room for noncompliance and errors, thus increasing risk and exposure. In this new model, conditional payments are addressed for every Medicare beneficiary identified through the Section 111 process. Administrative decision points are removed from the equation, and reporting safeguards can be incorporated to ensure zero tolerance for potential compliance failure.
When claims are handled on a one-off basis for MSP compliance attention, it is often difficult to monitor the efficacy of a program. Data relative to the measurement of success and potential exposure is frequently isolated or not captured at all. However, under a holistic approach that addresses every Medicare claim, primary payers can now have unprecedented visibility into:
The programmatic process of identifying claims appropriate for conditional payments will avoid the administrative efforts of one-off referrals for services. Fixed protocols surrounding thresholds for initiating Medicare conditional payment disputes — and for any decision point in the process — will remove time-consuming administrative decisions. This new programmatic model for MSP compliance:
Addressing Medicare conditional payments programmatically allows primary payers to capitalize on potential dispute opportunities to eliminate conditional payment costs and exposure.
As an example of the potential results in this type of model, here are some statistics from a large national workers' compensation insurer that opted for a programmatic approach to disputing conditional payments:
By looking at Medicare compliance using this holistic model, primary payers have an exceptional opportunity to capitalize on a programmatic approach. Such an approach offers almost 100 percent compliance through a streamlined process that will save time and money and mitigate against potential risk and exposure — and provide unprecedented visibility into the Medicare compliance process.
Carrie Barr is senior vice president of Sales and Services at ISO Claims Partners, a leading national provider of services that assist insurers, third-party administrators, and self-insureds with requirements related to Medicare compliance and improving claims outcomes.
Shawn Deane, Esq., is director of product development at ISO Claims Partners.