MMSEA CMS Section 111 Reporting Agents – Partner or Representative?

Qualities of a Successful Reporting Agent

John MianoMany Responsible Reporting Entities (RREs) have contracted with Reporting Agents for exchange of Section 111 Mandatory Insurer Reporting (MIR) data with the Center for Medicare and Medicaid Services (CMS).  However, as we approach the 4th quarter of 2011, and the first quarter of 2012 is looming in the not too distant future, RREs should be preparing to report liability claims to CMS, perhaps for the first time.  This is the perfect time for RREs to re-evaluate their relationship with their current Reporting Agent.

Some Reporting Agents may claim mastery or successful CMS MIR submissions but are they merely an “official reporting representative” or do they offer additional key value as partner in Medicare compliance?

Here are 5 key attributes of a good Reporting Partner:

  1. Flexibility
  2. Some RREs self administer claims and may also utilize third party claim administrators to handle and report claims. A Reporting Partner should be capable of consolidating data from multiple data sources and/or differing data types and formats. This flexibility is critical to expedient implementation of timely reporting. Does your Reporting Agent require you to register and maintain several RRE IDs due to lack of this flexibility?

  3. Technical Processes
  4. Selecting claim records for timely initial and subsequent MIR submission per CMS requirements and event tables is a difficult process. A Reporting Partner provides automated file selection and reporting of customer submitted, qualified claim records for quarterly reporting. What are your Reporting Agent’s automated and manual processes for CMS Section 111 Reporting and submission to CMS? Should the Reporting Agent filter, change or modify customer data prior to CMS submission, do you know what’s been changed? Is your claim, risk or matter management system still the system of record?

  5. Compliance Tools
  6. Provision of CMS threshold communications and record acceptance rates assist RREs with compliance performance information only after data has been submitted to and processed by CMS. A Reporting Partner empowers customers by providing management tools and data validation prior to proactively managing CMS submissions and MIR performance. Reporting Agents provide Query and Claim Responses from CMS, is this enough?

    Where CMS Section 111 reporting identifies RREs as the primary payers, Medicare Secondary Payer (MSP) compliance issues (such as exposure to conditional payments) may arise requiring timely recommendations and services. A Reporting Partner offers its customers a selection of MSP compliance plans which allow for proactive identification of exposure and assignment of services designed for the customers desired handling procedures. Does your Reporting Agent have the capability to identify MSP exposure or the expertise to provide necessary services for proactive MSP compliance?

  7. Communication
  8. Communication regarding customer data and CMS processing is critical to successful MIR performance. Questions ranging from field definitions, data mapping, operations training and responses to CMS should be easily resolved via e-mail or telephone. A Reporting Partner provides central points of contact regarding technical, operational and legal questions for expedited communication and response. If you currently have a question or issue, do you have a single point of contact at your current Reporting Agent you would call?

  9. Leadership
  10. MIR requirements, definitions, and specifications continuously change as CMS becomes more familiar with the industry and what data they wish to collect. A Reporting Partner is one who actively participates in special programs, CMS Town Hall teleconferences, is an industry advocate, and supports groups to build relationships, expertise and drives results. Is your Reporting Agent passive, passing along CMS Alerts and memoranda and simply responding to change?

The customer and RRE faces exposure in complying with MMSEA Section 111 Reporting and the MSP Act. How well does your Reporting Agent perform and what have they done for you lately?

These 5 attributes should help you determine whether your Reporting Agent is measuring up to the exacting standards that compliance requires and if they are ready for to begin reporting liability claims to CMS at the beginning of the first quarter of 2012.


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).

Medicare Secondary Payer Act PA Superior Court Ruling

Medicare Secondary Payer Act Sways  PA Superior Court Ruling

Pennsylvania State Seal www.statesymbolusa.orgThe Superior Court of Pennsylvania recently upheld a ruling in the Court of Common Pleas which has created somewhat of a stir in the Medicare Compliance industry in recent days. Those familiar with the Medicare Secondary Payer (MSP) Act, however, are not surprised by what the court made plain: MSP Compliance must not be merely an afterthought in tort litigation. MSP issues must be dealt with before the case goes to trial and, indeed, before settlement negotiations begin. The mere suggestion of a potential conditional payment lien is not enough, the court concluded, to hold off enforcement of a verdict. Further, the court found that a defendant cannot pursue lien rights that belong to the United States alone.

In Zaleppa v. Seiwell, defendant Seiwell backed her automobile into a vehicle occupied by plaintiff Zaleppa, causing personal injury. At the time of the accident, Zaleppa was sixty nine years of age and a Medicare beneficiary. A jury awarded Zaleppa $15,000.00, $10,000.00 of which was compensation for physical pain and suffering, mental anguish, etc.

After the verdict, Seiwell argued that the Medicare Secondary Payer Act required Medicare’s interests to be taken into account where conditional payments may have been made. On that basis, Seiwell requested that the court allow her (and her liability carrier) to include the plaintiff, her attorney and Medicare as a payee on the draft in satisfaction of the verdict or to pay the verdict into the court until Medicare notified the court that any lien was satisfied.

The trial court denied the motion, essentially finding that the defendant’s inaction regarding Medicare’s interests did not operate to stave off the enforcement of the verdict. On appeal, the Superior court nicely analyzed the MSP Act in addressing the core question: Can a private entity (Seiwell) assert the rights of the United States government regarding potential Medicare reimbursement?

Court Rules that Obligation to Reimburse was Triggered Before Tort Litigation Established

Seiwell, quite correctly, argued that as the “primary plan” she and her liability carrier were responsible for conditional payments made to Zapella, if any. What Seiwell failed to establish, however, was the existence of a Medicare lien. The court specifically recognized that if a lien existed, MSP required the primary plan to reimburse Medicare. Significantly, the court found that a recovery demand letter, issued by Medicare, triggers the primary plan’s duty to reimburse Medicare yet also acknowledged that payment to the plaintiff triggers reimbursement rights. Despite the fact that liability is established upon payment of a judgment, the mere fact of liability for MSP does not entitle a party to post trial relief until the obligation to reimburse has been triggered.

In its analysis of the MSP, the court found that there is a fundamental difference between Medicare’s right of reimbursement and the obligation of a primary plan. Nothing in the MSP, they reasoned, authorizes a primary plan to assert Medicare’s rights as a method to guard against their own liability. Only the U.S. government is authorized to pursue its own right of reimbursement.

The Pennsylvania court also added its “two cents” to the body of case law on conditional payments. Where Medicare’s interests are raised, the primary plan must show both the existence of a lien by affirmative evidence (a Medicare lien letter) but are not empowered to pursue Medicare’s interests under the private cause of action until they are actually damaged.

PA Court’s Decision Illustrates That Ignorance or Neglect of Medicare’s Interests Carries Consequences

The Pennsylvania decision again illustrates the fact that ignorance or neglect of Medicare’s interests has dire consequences. In the Seiwell case, had the primary plan taken the simple step of requesting and receiving a lien amount from Medicare, the interests of the U.S. government would have been placed at issue and addressed in the verdict phase. Instead of seeking to limit liability by raising Medicare’s interests until after a verdict is entered, parties must be aware that Medicare reimbursement must be addressed in every case. The Seiwell case is yet another example of what is becoming an increasingly clear message: Medicare’s interests must be identified and dealt with as early as possible and to ensure compliance and avoid penalties.

Section 111 Mandatory Insurer Reporting

Time Is Running Out on Section 111 Mandatory Insurer Reporting

Please join us on Monday, December 6th at 3:00pm EST for an important webinar concerning the changes to Medicare Mandatory Insurer Reporting Compliance requirements. After our December 6th webinar, there will only be  25 days left until the MMSEA Section 111 Mandatory Insurer Reporting (MIR) requirements go into effect on January 1, 2011.

If you are not prepared or you do not understand the stringent Medicare Mandatory Insurer Reporting MSP Webinarcompliance requirements… you could be liable for substantial fines and penalties…$1000 per day per claim.

Are you ready? Do you fully understand the legal implications of MIR compliance? Even if you THINK you are ready… register now for our Mandatory Secondary Payer (MSP) Reporting webinar scheduled for December 6th at 3:00 pm EST. John Miano, Manager of Gould and Lamb Client Services and nationally recognized MSP expert, Tom Blackwell will be available to address your questions and concerns following the webinar. Register now to have the opportunity to confirm that your processes are in place.

Section 111 Mandatory Insurer Reporting Attendees will receive:

•    Overview of the Section 111 Mandatory Insurer Reporting (MIR) process
•    Overview of testing with Gould & Lamb and CMS
•    Legal implications of MIR compliance
•    Legal implications of MSP compliance
•    Discussion of upcoming changes in settlements
•    Questions & Answers Session

Do not delay…space is limited. Click to Register Now and join John Miano and Tom Blackwell in this crucial and informative webinar. If you have questions or need additional information about this webinar, please contact us at 866-672-3453 ext 2020 or email us at clientservices@gouldandlamb.com.  Time is running out, please join us!


Mandatory Insurer Reporting TPOC

3 TPOC Truths on CMS Mandatory Insurer Reporting

I shared a passionate article John Miano, our Manager of Reporting Services wrote recently about the upcoming CMS Mandatory Insurer Reporting due to take effect January 1, 2011. John understands the importance and inherent ramifications our clients will face if they are not properly prepared when Mandatory Insurer Reporting takes place. In this article, John offers astute insights and answers questions many of you have asked.Centers for Medicare Medicaid Services

Written by John Miano, Manager of Reporting Services, Gould and Lamb

As we approach the Mandatory Insurer Reporting mandate of January 1, 2011, serious questions remain as to issues such as the identity of the Responsible Reporting Entity (RRE) and who must report a Total Payment Obligation to the claimant or TPOC (settlement, judgment award or other payment).

By now, most in the industry know the basics; RRE’s are required to report claims where ongoing responsibility for medical benefits (ORM) exists as of January 1, 2010 and are subsequently required to report  TPOC amounts when the TPOC settlement date is October 1, 2010 or later.

In the latest version of their User Guide, CMS provides guidance:

Section 7.1 – Who Must Report, explicitly defines the differences between Deductible versus self insured retention (SIR) programs and identifies issues specific to Deductible versus Re-Insurance, Stop Loss, Excess and Umbrella Insurance programs. Sections 11.4 and 11.5 clearly specifies TPOC Interim Reporting Thresholds and reporting of multiple TPOC’s.

Questions amongst insurers, however, have deepened as to who must report and the TPOC amount each RRE must report.

CMS TPOC Definition Overrules Insurer Description

NGHP Mandatory Insurer Reporting User GuideIf it walks and quacks like a duck, it’s a duck regardless of how it is perceived by the industry. In determining who the RRE may be, keep it simple; CMS acknowledges that their definitions differ from those utilized by the industry. Instruments of insurance are often identified by different names dependent on company or jurisdiction.

Example – A program behaves similar to reinsurance but has other customer specific components. The most general definition and intent should be applied when referring to CMS definitions. guidelines for the applicable plan per the NGHP User Guide should be applied.

With One Exception, RRE’s MUST REPORT TPOC Amounts

Each RRE must report those TPOC amounts (assigned or proportionate share) for which they are responsible.

The only notable exception is in regard to Liability Claims in jurisdictions which specify joint and several liability. Each RRE must report the total amount of the TPOC and not the assigned or proportionate share.

When In Reporting Doubt: CMS Is King

The only expert regarding Mandatory Insurer Reporting (MIR) is CMS. Should you have unresolved questions affecting timely compliance, CMS is the only true expert to be utilized. Any other opinion from a third party or legal counsel is just that, an opinion or interpretation.

The best place to start is with the Coordination of Benefits Contractor (COBC) Electronic Data Interchange (EDI) Representative assigned to the RRE. If you are unsure as to the identity of the EDI Representative, contact the COBC EDI Department at 646-458-6740 and ask for assistance. Outlines in Section 18.2 of the CMS User Guide are contact protocols and escalation processes.

Gould and Lamb, LLC has successfully transmitted data via OneSource on over 1100 insurance claims. The query process has been in place since July, 2009 evidencing that G&L is prepared for the reporting process and to assist clients with their ongoing mandatory insurer reporting benefits (ORM) and TPOC obligations. While the User Guide is unclear in many respects, the above observations in conjunction with the guide itself will help to avoid confusion and ensure compliance.

Click Here to Download the MSP Compliance Protocols User Guide from Gould and Lamb
Download Gould and Lamb’s Medicare Secondary Payer Compliance and Protocols User Guide

Download the MSP Compliance Protocols user guide today!

CMS Reporting Penalty Will Be $1000 per Claim per Day

$1000 per Claim per Day Effective January 1, 2011

I normally do not like “scare-tactics” as a way to get our client’s attention.  However, I am making an exception to that philosophy in deference to the CMS upcoming deadline for Mandatory Insurer Reporting that will take effect on January 1, 2011.

John Miano is Gould and Lamb’s Manager of Reporting Services.  He is so passionate about his job and making sure our clients do not get caught in the CMS reporting penalty for non-compliance that I have to share a recent alarming article he wrote:

Written by John Miano, Manager of Reporting Services, Gould and Lamb

You’ve been here before; ready to commit but there’s concern. Your new partner is complex, demanding and you’ve been left waiting. You have made several attempts at getting his/her attention but the timing has never been right. Your partner just keeps ignoring you. Your peers tell you the relationship will never work…just forget about it.

Does this sound like a new episode of Jersey Shore?  Maybe, but it most likely describes the relationship of our industry with CMS reporting requirements for MMSEA Section 111 and the deadline for MIR compliance changes going into effect on January 1, 2011.

Gould and Lamb and our clients have been ready to commit to providing data for MIR in the past, only to have CMS push the mandate back, alter the rules and change specifications.

Even with these CMS delays, the Quarter 1 mandate is real. A sufficient number of Responsible Reporting Entities – RRE’s have provided data to CMS voluntarily to indicate that the industry is prepared.

Less than 30 days to have production data to Gould and Lamb for October 18th Query Input Deadline

What this means for Gould and Lamb’s MIR customers, RRE’s and Claims Administrators NOT currently in production is that it’s time to wrap up testing and move to production NOW!.

Medicare Eligibility of the injured party is the first of many criteria for MIR for CMS reporting. Therefore, Query Input files must be submitted to and Query Responses received from CMS timely to ensure sufficient preparation of MIR claim record data.

The query input file requires a small number of basic data such as the RRE ID, the injured party’s first name, last name, gender, date of birth and social security number. The injured party information should be as it appears on his or hers Social Security of Medicare Card to ensure the best chance of receiving an accurate response from CMS.

In short, a Reporting Group 1 RRE must have production data to Gould & Lamb by October 18, 2010 to ensure sufficient time for the Query Response and preparation of data for January 1, 2011 MIR reporting date. The non-compliance CMS reporting penalty is high – $1,000 per claim per day.

Time is short, do NOT get caught in CMS’s $1,000 per claim per day reporting penalty. Contact your Client Liaison Specialist at Gould and Lamb today at Onesource.support@gouldandlamb.com or 866.672.3453 Ext. 1122.


Click Here to Download the MSP Compliance Protocols User Guide from Gould and Lamb
Download Gould and Lamb’s Medicare Secondary Payer Compliance and Protocols User Guide

Download the MSP Compliance Protocols user guide today!