Setting a New Standard to Predict Future Medical Costs
CMS Hosts Town Hall & Care Bridge International Hosts Technology Ethics Education
On April 1st CMS hosted the Benefits Coordination & Recovery Center (BCRC) and Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Town Hall via Conference line format. Having both recovery entities on this call served to reaffirm the specific responsibilities of each and to clarify / respond to some industry related issues involving MMSEA Section 111 reporting and the recovery centers.
The BCRC is responsible for ensuring Medicare beneficiaries repay Medicare conditional payments related to a workers’ compensation, liability, or no-fault claim.
The CRC is responsible for ensuring that Insurers’repay Medicare conditional payments.
2. Issues pertaining to Ongoing Responsibility for Medicals (ORM) and International Classification of Diseases (ICD) diagnosis codes.
We often discuss the importance of identifying the appropriate accepted/ compensable diagnosis codes, involving an injury claim, because if inaccurate codes are reported to CMS via MMSEA Section 111 reporting, there is a downstream effect that will cost you a lot of time, resources, aggravation and money.
We have found through data analysis that close to 70% of claims are first reported as a symptom, as opposed to a diagnosis.We also find through the MMSEA Section 111 reporting data, that often diagnoses codes are reported to CMS by an Insurer, inclusive of all diagnosis found in a medical record, even non-related and co-morbid conditions which are not accepted as compensable to the injury.
This finding is so common, that Care Bridge International uses its technology to identify the primary compensable diagnoses to ensure proper reporting, via its risk enterprise management MSP Compliance program, to avoid downstream problems.
Discussed on the CMS Town Hall were ORM and diagnosis code issues in scenarios involving multiple injuries and how to “clean up” the reporting data file to reflect the accuracy of the scenario. Where the reported diagnoses conflict with the conditional payment, the impact on Civil Money penalties, is a great concern to Responsible Reporting Entities (RREs).
The issue of correctly reporting compensable diagnosis codes to CMS is a systemic issue across most claims organizations and it requires a good, old-fashioned root cause analysis (RCA) and strategic process mapping to create an effective solution to ensure proper reporting to avoid the issues addressed on this town hall.