Reporting -- OIG Section 111 Audits, Thresholds and No-Fault Settlements

Section 111 Audits are coming.  The Health and Human Services (HHS) Office of Inspector General (OIG), which generally focuses on Medicare fraud and improper billing by providers has added auditing Responsible Reporting Entities (RREs) to their list of audits for next year.  Specifically, they stated in their 2013 Work Plan that they will determine whether selected non-Medicare health plans properly reported insurance coverage information under the Medicare, Medicaid and SCHIP Extension Act of 2007, §111 to Medicare as required.

The Centers for Medicare and Medicaid Services (CMS) has often stated that they are more interested in encouraging reporting than levying fines, but the OIG, which has recently made headlines with record settlements against large pharmaceutical companies and busting Medicare fraud rings, may be less forgiving.  Now would be a good time to review your reporting processes to avoid giving the OIG an opportunity to pursue the $1000 per day per day fine per unreported beneficiary mandated under the Section 111.

Providers and pharmaceutical companies should be most concerned about the fines.

Since providers are regularly audited it would be natural for the OIG auditor to audit their Section 111 compliance while they are there.  In addition to the normal reporting requirements, providers should review our article about reporting hospital write-offs If the provider is also engaged in conducting clinical trials then the risk is even greater (see our articles about clinical trial reporting later in this news letter and on our web site at PiattConsulting.

Pharmaceutical firms are at risk because, aside from already being on the OIG radar, Medicare is aware that they have been hesitant to begin reporting.

Thresholds -- Remember that if the most recent TPOC Date is on or between October 1, 2012 and September 30, 2013, and the cumulative TPOC Amount is greater than $5,000, the TPOC(s) must be reported no later than the end of the RRE’s submission timeframe in the quarter beginning January 1, 2013.  Run your queries this month for settlements over $5000.  The next scheduled threshold reduction to $2,000 is scheduled for October 1, 2013.

Reporting No-Fault -- No-Fault insurance should generally be reported as Ongoing Responsibility for Medicals (ORM) equals ‘Y’ (yes), indicating that the insurer is responsible for paying medical claims to providers up to the limit reported under the No-Fault Insurance Limit (field 81).  Once that limit has been met or the insurance otherwise exhausted, then the RRE should report that fact by adding the Exhaust Date for Dollar Limit for No-Fault Insurance (field 82) and terminating their responsibility using the ORM Termination Date (field 92).  If the No-Fault insurer disbursed some of the funds to  the beneficiary, then they should report that as an TPOC / TPOC Date as well.  CMS will seek to recover conditional payments from such a disbursement from the beneficiary.

If the No-Fault insurer settled the case without an obligation to make payments  to providers, then the No-Fault insurer should still report the case as a No-Fault insurance (e.g., not a liability settlement), but set ORM equal to ‘N’ and report the settlement amount under TPOC / TPOC date along with the other data required for reporting  including the No-Fault Insurance Limit (field 81) and Exhaust Date for Dollar Limit for No-Fault Insurance (field 82).