Why is Medicare requesting Multiple Total Obligation Payment to Claimant (TPOC) fields

CMS Alert 13 July:

"In situations where the applicable workers’ compensation law or plan requires the RRE to make regularly scheduled periodic payments to, or on behalf of, the claimant, and the applicable workers compensation law or plan specifically precludes these periodic payments from including any direct or indirect payment for past, present, or future medical expenses; the RRE does not report these periodic payments (they are not reportable as either TPOCs or ORM). Otherwise, these payments are considered to be part of and are reported as ORM."

During July 13th teleconference, CMS indicated that the requirement to make separate lost wage payments may be adequate to fulfill the requirement -- ed.  Be sure to consult the next release of the NGHP User Guide for specific instructions.

UPDATE 28 May 2010

CMS changed course during their 27 May 2010 Town Hall conference.  Now an insurer has no option, but to report if they make any payments including indemnity payments.  In essence, CMS stated that if the RRE is making indemnity payments, then the RRE has implicitly, if not explicitly, accepted ORM. If an insurer makes periodic payments for obligations other than medical payments, the the RRE does not report the individual payments as long as they report ORM.

Impact on Beneficiary and Medicare Secondary Payer Recovery

If the payments are, in fact, strictly indemnity payments (as the City of Boston makes for retired emergency workers), then one assumes that the insurer or carrier will be forced to report old injury codes.  If those medical costs were compromised and Medicare recovers their conditional payments from the settlement, Medicare should be primary -- not denying the beneficiary's claims based on out-of-date codes.

Forcing insurers and carriers to accept ongoing responsibility for medicals where none exists will unnecessarily complicate recovery efforts.  The Medicare Secondary Payer Recovery Contractor, will incorrectly send demands for reimbursement to the insurer or carrier.  If the case was compromised, Medicare has a right to recover conditional payments, not to insist the insurer or carrier continue to pay medical costs.  If the case was commutated, then funds allocated to future medical costs become the "plan" and Medicare should send demand letters to the future medical plan, not the insurer or carrier.