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.

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.

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  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 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!