Author: daniel.anders

Removal of SSN from Medicare IDs Detailed in CMS Open Door Forum

January 23, 2017

On January 17, 2017, the Centers for Medicare and Medicaid Services (CMS) held a Special Open Door Forum to detail how the Social Security Number Removal Initiative (SSNRI) impacts the Medicare Secondary Payer (MSP) community. CMS’s explanation is summarized below with Tower MSA’s thoughts on the practical implications of this change.

SSNRI Explained

Presently, Medicare beneficiaries are assigned a Healthcare Insurance Claim Number (HICN) which generally includes either their or their spouses Social Security Number (SSN) followed by a letter, commonly an A or B. For the purpose of reducing identify theft involving SSNs, the Medicare Access and CHIP Reauthorization Act of 2015 included a provision requiring CMS to remove SSNs from all Medicare cards by April 2019.

In accordance with the Act, CMS announced that starting in April 2018 it will begin to issue what will be called Medicare Beneficiary Identifiers (MBIs) to replace the HICNs currently in use. MBIs will be 11-alphanumeric characters in length with letters only in uppercase. The MBIs will be assigned to approximately 60 million current Medicare beneficiaries and 90 million deceased/archived Medicare beneficiaries. CMS targets completion of the assignment of MBIs by April 2019.

CMS advised there will be significant outreach to Medicare beneficiaries, medical providers, and other stakeholders, such as the Medicare Secondary Payer community, prior to implementation of this change.

CMS has a dedicated website regarding the SSNRI which may be found here.

SSNRI Impact on MSP Compliance

In regard to Medicare Secondary Payer compliance processes, the MSP compliance community currently exchanges data with CMS through Section 111 Mandatory Insurer Reporting, the Medicare Secondary Payer Recovery Portal (MSPRP) and the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP). CMS made the following statements concerning the SSNRI’s impact on this exchange of information:

• Fields presently identified as HICN will be retitled “Medicare ID.”
• As the HICN fields currently accept 11 characters there will be no expansion of these fields as a result of the implementation of MIBs.
• SSNs can continue to be used for querying whether a particular claimant is a Medicare beneficiary through the Section 111 Reporting process and for communication through the MSPRP and WCMSAP.
• Use of partial SSNs will continue to be permitted for querying Medicare eligibility.
• After April 2018 the CMS response to a Section 111 query will either provide the HICN or the MBI, depending upon whether the particular Medicare beneficiary has been issued an MBI.
• Outgoing documentation through the MSPRP or WCMSAP will include the HICN or MIB, depending upon what was most recently reported. For example, if an MSA is submitted to CMS for review through the WCMSAP and contains a HICN, then the response from CMS will include the HICN. On the other hand, if an MIB is submitted, then the CMS response will include the MIB.

Treasury Department to No Longer Include Medicare ID

Also announced during the forum is an impending change by the Treasury Department to no longer include the HICN (or the MIB when it becomes active) in its correspondence stemming from Medicare conditional payment recovery. Instead, the Treasury Department will only list the Case Recovery ID that has been assigned to the case by either the Benefits Coordination and Recovery Contractor (BCRC) or the Commercial Repayment Center (CRC). This change is expected to occur before the end of 2017.

Practical Implications

An important takeaway from CMS’s explanation of the SSNRI is that for MSP compliance purposes we can continue to use SSNs in communicating with CMS and its contractors. What we should recognize is that as of April 2018 besides SSNs, claimants may be providing MIBs rather than HICNs. Further, it should be recognized that the Section 111 query process may return an MIB, rather than an HICN, starting in April 2018.

Our Tower MSP Automation Suite will seamlessly transition to recognition and reporting of MBIs for Section 111 Reporting purposes starting in April 2019. We do recommend to our clients that they confirm their internal claims database will be fully capable of recognizing the MBIs when they become active for Medicare beneficiary claimants.

Finally, the Treasury Department’s removal of any Medicare beneficiary identifier from its conditional payment recovery correspondence may present some difficulty to workers’ compensation, liability and no-fault plans in identifying the particular claimant from which the demand stems. Tower MSA will work with our clients to address any uncertainty, but we also recommend to our clients that they work with us to actively resolve Medicare conditional payments on open and settling claims such that these demands never are referred to the Treasury Department.

If you have any questions regarding the SSNRI, please contact Tower MSA Partners Chief Compliance Officer, Dan Anders, at (847) 946-2880 or Daniel.anders@towermsa.com

CMS MSA Review Expansion to Liability Planned for 2018

January 4, 2017

We are not even a week into 2017, but already have news to share regarding Medicare’s planned expansion of its Workers’ Compensation MSA review process to liability in 2018. In its recently released Request for Proposal for the Workers Compensation Review Contractor (WCRC), the Centers for Medicare and Medicaid Services (CMS) includes an option allowing CMS to expand the responsibilities of the WCRC to review of Liability Medicare Set-Asides (LMSAs) and No-Fault Medicare Set-Asides (NFMSAs) effective July 1, 2018.

The CMS WCRC RFP Solicitation may be viewed here.

Background on CMS Review of MSAs

Since 2001 CMS has had in place an official voluntary review process for Worker’ Compensation Medicare Set-Asides (WCMSAs). A WCMSA, as CMS states, is a “financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury.” The purpose of the review then is “to independently price the future Medicare-covered medical services costs related to the WC injury, illness, and/or disease and to price the future Medicare covered prescription drug expenses related to the WC injury, illness and/or disease thereby taking Medicare’s payment interests appropriately into account.”

These WCMSA reviews were initially handled by the CMS Regional Offices spread throughout the country, but eventually transitioned to a centralized WCRC in 2005 (The CMS Regional Offices must still approve the review recommendation of the WCRC before it is released to the WCMSA submitter). CMS’s RFP solicitation for the new WCRC contract indicates the contract is to be awarded by June 30, 2017 with a contract term running for five years from July 1, 2017 to June 30, 2022.

Expectations for Liability MSA Reviews

Presently, CMS allows its 10 Regional Offices to accept voluntary requests for review of LMSAs at each office’s discretion. Some Regional Offices have consistently refused to review any LMSAs while other offices agree to review based upon criteria that seemingly changes over time and bears no indication that it is indeed the official policy of CMS. It appears then that just as it did in 2005 when CMS took the responsibility away from the Regional Offices for reviewing WCMSAs, CMS is now considering centralizing the process of reviewing LMSAs with a contractor, leaving the Regional Offices to only approve of the contractor’s recommendations.

Some may recall CMS launched a prior initiative to establish a formal policy for consideration of future medicals in liability settlements when it issued an Advanced Notice of Proposed Rulemaking in 2012. This initial effort was ultimately withdrawn by CMS in 2014. CMS’s new initiative began with this June 9, 2016 notice on the CMS website:

The Centers for Medicare and Medicaid Services (CMS) is considering expanding its voluntary Medicare Set-Aside Arrangements (MSA) amount review process to include the review of proposed liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS plans to work closely with the stakeholder community to identify how best to implement this potential expansion. CMS will provide future announcements of the proposal and expects to schedule town hall meetings later this year. Please continue to monitor CMS.gov for additional updates.

No town hall meetings were scheduled in 2016, however, based upon this RFP indicating LMSA reviews will not begin until at least July 1, 2018, CMS has given itself 18 months to develop and implement a formal LMSA review policy. In terms of how many liability settlements such a review process would impact, CMS seems uncertain. A Statement of Work attached to the RFP indicates “reviews could represent as much as 11,000 additional cases (based on all FY2015 NGHP demands), or as little as 800 additional cases annually, depending upon industry response.”

Tower MSA Takeaways

Over the past 15 years, starting with the formalized review of WCMSAs, continuing with the implementation of Section 111 Mandatory Insurer Reporting and recent stepped up efforts at denying injury-related medical care and recovery of conditional payments for medical care related to workers’ compensation, liability and no-fault claims, CMS has expanded its enforcement under the Medicare Secondary Payer Act. It is not surprising then that CMS’s next objective is formalizing a voluntary review process for LMSAs.

It has been our experience that when CMS does implement new policy and procedures it does take a deliberative approach evidenced by the at least 18-month timeframe signaled with this RFP to expand the MSA review process to liability and no-fault. Our expectation then is over the next 18 months or longer, CMS will provide additional announcements concerning the rules and procedures around expansion of the review process.

Tower MSA will be involved in these discussions and will keep you abreast of relevant developments. In the interim, there remain important obligations of parties to liability settlements and no-fault claims under the Medicare Secondary Payer Act. Rest assured that you can rely upon Tower MSA’s team of MSP compliance experts for consultation and expert guidance in liability and no-fault matters.

If you have any questions, please contact Tower MSA Partners, Chief Compliance Officer, Dan Anders, at (847) 946-2880 or daniel.anders@towermsa.com

CMS Announces Plans for 2017 Expansion of MSA Re-Review Process & New Policy Regarding URs in MSAs

December 22, 2016

Employers, carriers and claimants frustrated by the inability to obtain a revised CMS MSA approval after a substantial change in the claimant’s pre-settlement medical condition may find relief from CMS in 2017. Also in 2017, CMS will be issuing a policy regarding use of utilization reviews in MSA submissions. These potentially significant improvements in the CMS MSA review process are provided in a 12/21/2016 “teaser type” announcement on CMS’s website which states:

The Centers for Medicare & Medicaid Services recently revisited the task of reviewing its process for addressing requests for CMS to “re-review” otherwise approved Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts. In Calendar year 2017, CMS expects to update its existing re-review process to address situations where CMS has provided an approved amount, but settlement has not occurred and the medical care that supported the approved amount has changed substantially. CMS also expects its updated process to address situations where certain states rely on Utilization Review Processes to justify proposed WCMSA amounts.

A link to the announcement may be found here.

What are the implications of this announcement from CMS?

No immediate change to CMS MSA review policies

Importantly, this is an announcement of an expected change to the MSA re-review process and the introduction of a UR policy in 2017. CMS provides no timeline beyond future announcements will occur in 2017. Consequently, there is presently no change to CMS MSA review processes or policies.

Substantial change in medical may present opportunities for revised MSA approvals

The announcement implies CMS will be expanding its MSA re-review process to cover MSA approvals where there has been a “substantial change” in the claimant’s medical condition. According to the CMS statement, this policy would only apply to cases “where settlement has not occurred.” In other words, if settlement has occurred (we assume settlement of medical) CMS will not consider a re-review.

Based upon the limited announcement it is also unclear how CMS will define “substantial change.” For example, must an actual reduction in medical care and/or prescription medication use be documented or simply a certain monetary threshold increase or decrease versus the prior MSA amount be demonstrated? This is an important question CMS will have to address as while a claimant’s medical care may not have substantially changed, the cost of the claimant’s prescription medications may have substantially reduced such as when a medication goes generic.

While the definition of “substantial change” will be the subject of a future CMS policy announcement, Tower MSA nonetheless expects this MSA Re-Review expansion to present a significant opportunity for carriers/employers and claimants to settle medical on cases which have languished unsettled for years as a result of prior high CMS MSA approvals. Reductions in a claimant’s medical costs over the years or the successful implementation of a plan to reduce a claimant’s inappropriate prescription medication regimen will yield not only a lower MSA allocation, but CMS approval of this updated MSA. The opportunity for an updated and lower MSA will facilitate claim settlements and closures.

Wait and see approach warranted regarding CMS policy on URs

The extent CMS will recognize state Utilization Review processes remains unclear based upon this announcement. Presently, CMS generally recognizes California UR determinations as a limitation on medical care in the MSA if upheld through the statutory Independent Medical Review (IMR) process as the IMR component is understood by CMS to be a final determination subject to appeal only under very limited circumstances. Other state UR processes have not been recognized as they are not considered by CMS to be final determinations. Accordingly, Tower MSA recommends taking a wait and see approach to how CMS defines its policy on URs in MSAs.

Concluding thoughts

Tower MSA applauds the potential expansion of the CMS MSA Re-Review process to encompass pre-settlement MSA approvals where there has been a substantial change in medical care as this gives carriers/employers and claimants a second-chance to settle long-standing open medical claims. We are also hopeful CMS will expand its policy on recognizing state UR process beyond California’s IMR process. We will closely monitor CMS for an announcement concerning the implementation of this policy change and provide you further analysis and recommendations.

If you have any questions regarding this CMS announcement please contact Dan Anders, Tower MSA Chief Compliance Officer, at (847) 946-2880 or Daniel.anders@towermsa.com

CMS Technical Alert Confirms $750 Threshold for Liability, WC and No-Fault TPOC Reporting

December 13, 2016

In a 12/12/2016 Technical Alert, the Centers for Medicare and Medicaid Services (CMS) confirmed their prior policy announcements concerning the implementation of a $750 threshold for the reporting of Total Payment Obligation to the Claimant (TPOC) through the Section 111 Mandatory Insurer Reporting process. The $750 threshold for TPOC reporting in WC and No-Fault claims became effective 10/1/2016 and will become effective for liability claims effective 1/1/2017.

The mandatory reporting threshold requirements are now as follows:

Liability Insurance:
The mandatory reporting threshold for liability insurance (including self-insurance) Total Payment Obligation to the Claimant (TPOC) Amounts dated January 1, 2017 or after is changing from $1000 to $750. If the most recent TPOC Date is on or after January 1, 2017, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported.

Note, the liability threshold only applies to physical trauma-based liability insurance TPOC amounts. It is not applicable to TPOC amounts for alleged ingestion, implantation or exposure.

No-Fault Insurance:
The mandatory reporting threshold for no-fault insurance TPOC Amounts dated October 1, 2016 or after changed from $0 to $750. If the most recent TPOC Date is on or after October 1, 2016, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported.

Workers’ Compensation:
The mandatory reporting threshold for workers’ compensation TPOC Amounts dated October 1, 2016 or after changed from $300 to $750. If the most recent TPOC Date is on or after October 1, 2016, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported

CMS also announced that as of 1/1/2017 reporting of cumulative TPOC Amounts at or below the above defined reporting thresholds will be accepted, but are not required. In other words, submitting a TPOC amount below the mandatory reporting thresholds will no longer generate an error code by CMS.

The entire content of the official Alert from CMS can be found here.

If you have any questions regarding this Alert please contact Tower MSA Partners’ Chief Compliance Officer, Dan Anders, at Daniel.anders@towermsa.com or (847) 946-2880.