Section 111: What is Medicare missing?

Workers’ compensation and liability insurance carriers have the obligation to report two essential events if a claim involves a Medicare Beneficiary:

  • Ongoing Responsibility for Medical (ORM)
  • Settlement, judgment, award, or other payment

Medicare refers to a settlement, judgment award, or other payment as “Total Payment Obligation to Claimant (TPOC).”

These two events require the carrier/self-insured to tell Medicare about conditions associated with each event. The Commercial Repayment Center (CRC) is generally responsible for searching for payments associated with ORM. CRC sends its demand directly to carrier/self-insureds.

The Benefit Coordination and Recovery Center (BCRC) is generally responsible for searching of payments associated with TPOC. BCRC generally sends its collection directly to the claimant without notifying the carrier/self-insured.

When the carrier/self-insured reports ORM or TPOC to Medicare, there is specific information that is sent over to Medicare. This information is packaged up into a “claim input file.” Medicare’s Section 111 user guide identifies what and where information is needed for the claim input.

For example: Field “2” of the claim input file must contain the carrier/self-insured Responsible Reporting Entity ID number and must be numeric data.

However, with Medicare holding the cards on their system and the information it will receive, there is a disconnect between Medicare’s requirements and the nuances associated with a workers’ compensation claim and/or liability claim. Here are a few scenarios not encompassed in Section 111:

  • If conditions in ORM and TPOC are different, the claim input file has no place to separate this information. (i.e. settlement involves accepted shoulder, but denied hypertension)
  • No place to identify unauthorized providers, utilization review or disputes associated with the claim
  • No place to advise Medicare that carrier/self-insured has agreed to negotiate and reimburse TPOC search and collection

Medicare regularly advises these nuances can be handles through their administrative appeal process. However, among other reasons, the low quality of Medicare’s collection and timeliness of the process, create an unjust burden on carriers and self-insureds to correct Medicare’s mistakes. This can result in carrier/self-insureds waiting years for Medicare to finally come around and realize their collection is invalid.

Ideally, if Medicare can identify and accommodate these nuances at the front end, Medicare will spend more time accepting payments instead of handling appeals and referrals to U.S. Treasury. We are hopeful Medicare will evolve to perform its functions efficiently while capturing all charges payable under a workers’ compensation and liability claim. Until then, the burden rests in the stakeholder’s hands.