House Passes Measure to Delay ICD-10 Transition

STOP THE PRESSES… Possible Delay in ICD-10 Transition

By voice vote on Thursday, March 27, the House approved another temporary (one-year) fix to prevent steep cuts in Medicare’s physician reimbursement scheduled to take effect March 31. It now moves to the Senate which is expected to take action within the next few days. The draft legislation does not address the problems with the Workers’ Compensation Medicare Set-Aside approval process. However, there is language that speaks to a possible delay in the ICD-9 to ICD-10 transition, which could impact the MMSEA Section 111 mandate for reporting ICD-10s.  Other key inclusions include a two year delay in the provision overturning two U.S. Supreme Court decisions that prevented state Medicaid agencies from recovering 100 percent of their medical payments from the proceeds of liability settlements involving Medicaid beneficiaries and at least a one-year delay Medicaid mandated that providers move from ICD-9 coding to much more complex ICD-10 coding which will have a significant impact on insurers data reporting and bill payment functions.

CMS Issued Alert

It was only on this past Tuesday, March 25, 2014, that the Centers for Medicare and Medicaid Services (CMS) published an Alert regarding ICD-10 Diagnosis Codes, which further tightens the list of acceptable codes for Mandatory Insurer Reporting (MIR) purposes.

ICD-10 codes beginning with the letter “Z” are related to factors influencing health status and contact with health services, and are considered invalid for MIR.  This includes all 19 Diagnosis Code fields as well as the Alleged Cause of Injury, Incident or Illness field.

MIR ICD-9 Codes for Free

The Alert also clarifies the use of ICD-10 codes beginning with the letters V, W, X and Y.  These codes are related to external causes of morbidity and mortality, and may only be populated in the Alleged Cause of Injury, Incident or Illness field, as long as they are not on the list of excluded codes in the NGHP User Guide.  Additionally, these V, W, X and Y codes are invalid for use in the 19 ICD-10 Diagnosis Code fields.

Gould and Lamb has applied the appropriate quality audits, alerts, and metrics to ensure our customers are compliant with the transition.  Should you have any questions regarding this or any other topic related to MIR, please contact your MMSEA Compliance Manager or our Reporting Services Department at or 866-672-3453 ext. 1122.

Additional details on the bill can be found here.

CMS Clarifies Its February Alerts Regarding Section 111, MMSEA Reporting

Russell S whittle, Esq VP MSP ComplianceOn February 28, 2014 the Centers for Medicare and Medicaid Services (CMS) published its formal notice of the change in the reporting threshold for liability (including self insurance) settlements, judgments, awards or other payments.  The notice follows the recent publication of two Alerts of February 18.   Those Alerts announced a potential change in the Mandatory Insurer Reporting obligations of Responsible Reporting Entities pursuant to the changes instituted by the Strengthening Medicare and Repaying Taxpayers (SMART) Act.

In the new notice, CMS has advised that an updated Non-Group Health Plan User Guide, Version 4.2 Chapters I – V, can now be downloaded to incorporate the change in the Medicare, Medicaid and SCHIP Extension Act (MMSEA) necessitated by its February 18 changes and the SMART Act requirements.

CMS has now determined that, for certain liability insurance settlements, judgments, awards or other payments:

  • The Current mandatory reporting threshold for liability insurance (including self-insurance) Total Payment Obligation to Claimants is $2000 for settlements, judgments, awards or other payments occurring on or after October 1, 2013.
  • For settlements, judgments, awards or other payments exceeding $1000 on or after October 1, 2014, reporting is required no later than the first quarter of January, 2015.  This is a change from the previously published threshold amount of $300.
  • Error Code CJ07 – where Ongoing Responsibility for Medical has not been accepted and where the settlement, award or judgment amount does not meet the reporting threshold – will still occur on claims submitted with a cumulative TPOC Amount less than $300.  It is expected to be changed to coincide with the new $1000 reporting threshold later this year.

As had been discussed in the wake of the February 18 Alerts, questions had been raised regarding the effective date of the changes and the ability of CMS, from a technical standpoint, to implement them. The notice now puts a clear timeframe on the applicability of the change, the settlements to which they apply and the anticipated technical Error Code update.

Gould & Lamb will incorporate the new changes into its Mandatory Insurer Reporting Services program for all settlements that are effected by the change and will also add the appropriate logic to ensure Error Coding is consistent with any CMS update.

Why You Need to Align Yourself with the Right Reporting Agent

Quite possibly the single largest incentive to comply with the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) was the verbiage, “An entity… shall be subject to a civil money penalty of $1,000 for each day of noncompliance for each individual…”  The fear of an absolute penalty at the rate of $1,000 per claim per day is very persuasive.  The Strengthening Medicare and Repaying Taxpayers (SMART) Act, signed into law in early January 2013, softened the language in the statute such that an entity may be subject to a penalty of up to $1,000 per claim per day.  With the passing of the SMART Act, CMS was to provide further clarification as to what constitutes a lack of compliance with the MMSEA, including any safe harbors.  That verbiage has not yet been provided, so now is the critical time to ensure that you are properly aligned with a Reporting Agent that is fully committed to making you succeed in complying with the MMSEA.

Your claims should be properly vetted to determine which ones qualify for reporting and data deficiencies should be identified in advance of reporting to ensure acceptance by CMS.  While the Non-Group Health Plan (NGHP) User Guide (now in version 3.6) defines each field and the applicable error codes, there are many idiosyncrasies that go undocumented.  It is only when partnering with a Reporting Agent whom continuously reviews their own as well as CMS’ data validations that you can rest assured compliance with the MMSEA is fulfilled.  Your Reporting Agent must also provide you with a team of dedicated subject matter experts.  These SMEs are your lifeline with CMS EDI Representatives and management.  Without the proper people on your side, compliance with the MMSEA is extremely difficult.

If you are not fully comfortable with your current MMSEA Compliance Program, then I urge you to contact us today.

General Information

The 67th Annual Workers’ Compensation Educational Conference and the 24th Annual Safety and Health Conference are just around the corner. Set for August 19 through 23, 2012 at the Orlando World Marriott, the conference will again focus on the national workers’ compensation and safety industries, serving as a gathering of national stakeholders to study and be educated on issues of common concern.  For the first time, the Conference program has expanded to a fourth day (Thursday, August 23) with a full 2-day breakout for mediators.


As usual, this year’s program offers creative and innovative speakers from around the country. The hottest issues in workers’ compensation and safety will be discussed. All aspects of workers’ compensation and workplace safety will comprise the topics of discussion with breakouts for risk managers, regulators, safety professionals, health care providers, adjusters, insurance professionals, attorneys, medical case managers, professional employer organizations (employee leasing), temporary staffing, mediators, and medical office administrators.

Medicare Secondary Payer Act Compliance

Sponsored by Gould & Lamb, LLC, this year’s conference will again be the only national conference to feature a full-day breakout on the Medicare Secondary Payer Act and related subjects. One of the most difficult areas in handling workers’ compensation and general liability matters is understanding and dealing with the serious pitfalls that this expanding responsibility creates. The comprehensive breakout will clarify what has become an extremely complicated process that has created enormous issues for the workers’ compensation industry, soon to further expand into the general liability area.

Providing Clarity in a Land of Confusion

Program Moderator, Bret Cade, Executive VP of Sales at Gould & Lamb, LLC will lead the day long seminar. Planned presentations include Medicare Secondary Payer Act 101: The Reader’s Digest Version by Roy Franco, Esq., Principal at Franco Signor, LLC, The Eye in the Sky: Mandatory Insurer Reporting by Scott Huber, Vice President of Information Technology at Gould & Lamb, LLC and Jeff Gurtcheff, VP and General Manager at PMSI, Render Unto Caesar What is Caesar’s: Conditional Payments  Resolution by Wanda Reas, Esq., Partner at Znosko & Reas, P.A. and John Cattie with the Garretson Resolution Group, So Let It Be Written, So Let It Be Done: A Legislative and Case Law Update by Mark Popolizio, Esq., Senior Legal Counsel at Crowe Paradies and Roy Franco, Esq., Principal at Franco Signor, LLC, Seeing the Forest Through the Trees: MSA/LMSA Trends by Rafael Gonzalez, Director of Medicare Compliance & Post Settlement Administration at Gould & Lamb, LLC, Celia Mendez, Esq., Mediator & Attorney at Moreland & Mendez, P.A., and Cynthia Sage, Esq., Corporate Counsel at FCCI Insurance Group. The program will end with MSP Compliance in the Real World: A Roundtable Discussion where all of the previously mentioned speakers will be joined by Skip Brechtel, Chief Technical Officer at CCMSI, Wade McGuffey, Esq., of Goodman, McGuffey, Lindsey & Johnson, LLP, and the Honorable David Langham, Deputy Chief Judge of Workers’ Compensation Claims.

The program will:

  • Provide much needed technical information on Mandatory Insurer Reporting, addressing its purpose and expounding on reporting triggers, errors and challenges, as well as the consequences enumerated by Section 111 of the Medicare/Medicaid SCHIP Extension Act of 2007.
  • Present a comprehensive overview of the policies and procedures relative to the Medicare Secondary Payer Recovery Contractor (MSPRC), challenges in dealing with the MSPRC and consequences of not handling Conditional Payments appropriately.
  • Give attendees with a thorough review of new legislative initiatives and cases decided from around the country on both workers’ compensation and liability claims related to Medicare Set Asides and Conditional Payments.
  • Delve into current industry trends in workers’ compensation and liability Medicare Set- Asides, specifically regarding MSA submissions, MSA approvals, MSA pharmacy issues and MSA administration.
  • Offer those in attendance the opportunity to listen in on a roundtable discussion bringing legal and claims’ experts together to discuss their trials, tribulations, methods and best practices in complying with CMS’ policies to take Medicare’s interest into consideration when settling past and future medical care.

NGHP Section 111 Reporting Mid Year Review

John MianoWe’re a little more than half way through 2012 and thus far we have seen some significant changes in the Mandatory Insurer Reporting landscape.

The Center for Medicare and Medicaid Services (CMS) made long awaited updates to the Medicare Medicaid SCHIP Extension Act (MMSEA) User Guide for Non-Group Health Plans (NGHP).  These may have been the result of CMS listening to Town Hall teleconference attendees, fielding Section 111 e-mail submitter questions  and interacting with industry committees.

The latest version of the User Guide introduced new formatting with sections separated into functional categories. The new NGHP User Guide also includes additional charts and tables affording readers a better understanding of context and work flow.

CMS announced during a recent Town Hall teleconference the merging of functionalities between the Coordination of Benefits Contractor and the Medicare Secondary Payer Contractor. The industry will benefit from the increased efficiency in processing of MIR data and Medicare Secondary Payer identification and handling conditional payment liens.

While some changes have been beneficial, others have not been as effective.

Earlier this year, the Department of Health and Human Services (DHS) issued a Medicare Learning Center ‘News Flash’ advising Medicare fee for service providers on proper procedures for identifying primary payers and making correct and timely billing submissions to Medicare. Despite this notification and training of CMS contractors, there remain widespread reports of injured parties contacting insurers or their agents seeking remedy for affected Medicare treatment and services disrupted by NGHP Section 111 reporting. Along with the administrative burden on the industry, there is frustration over the inability to affect resolution.

The annual Responsible Reporting Entity (RRE) Profile Report confirmation and recertification process has proven to be an arduous task. Many legitimate RRE’s are in a discontinued status and have  become non-compliant. Clearly, improvements to communication and workflow are needed prior to January 2013 to prevent recurrence of the administrative log jam.

Lastly, there are issues which remain unaddressed, such as the reconvening of the Mass Tort group and creation of policy and guidance regarding NGHP Section 111 reporting.

In two quarters, we’ve witnessed increased organizational efficiencies with CMS contractors and much improved documentation.  There has been progress but many significant issues remain unresolved and will likely remain so for the foreseeable future.

NGHP Mandatory Insurer Reporting User Guide(NGHP) User Guide Version 3.4

About the Author: John Miano is the Manager of Reporting Services for Gould & Lamb, LLC. His primary responsibility is directing the implementation of CMS Section 111 reporting programs for our clients. He has over 20 years experience in the Property and Casualty Insurance Industry and is currently an active committee member of the International Association of Industrial Accident Board Committees (IAIABC). He is also a former Executive Board Member of the Association of Workers Compensation Claim Professionals (WCCP) and is a Board Certified Workers Compensation claim adjuster (CWC).

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.