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.
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
If 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.