You may remember the ad for a brand of soap that made the following claim: “99 and 44/100 Percent Pure: It Floats.” Like that iconic slogan, nearing 100 percent Medicare compliance is an accomplishment to boast about.

The goal of a programmatic approach is to obtain as close to total compliance as possible. When operating in an inefficient Medicare compliance environment and attending to claims ad hoc, there’s more room for error — increasing risk and exposure. In this new model, conditional payments are addressed for every Medicare beneficiary identified through the Section 111 process. Administrative decision points are removed from the equation, and reporting safeguards can be incorporated to avoid compliance ‘leakage’.

Recent changes to reporting and recovery involving Medicare contractors, new technologies and reporting capabilities and a more integrated approach have brought about incredible potential to maximise compliance, use repurposed Section 111 data points to automate the Medicare conditional payment process and gain unprecedented insight into risk across all claims. These changes can also increase opportunities to mitigate costs and exposure, reduce time for faster claim resolution and conserve claim-handling resources

Medicare conditional payment compliance

The Medicare Secondary Payer (MSP) Act provides the federal government with a unique statutory right to recoup Medicare payments made on behalf of beneficiaries involved in workers compensation, liability, and no-fault (PIP/med-pay) matters. The MSP Act generally prohibits Medicare from making payment when another form of insurance (a primary payer) is available to pay. This is essentially a coordination-of-benefits function.

However, Medicare will make a payment on the condition that it will be reimbursed when a primary payer has responsibility to make payment for treatment. This responsibility can be evidenced by a settlement, judgment, award or other payment. Essentially, Medicare can recover monies it reimbursed to providers for a claimant-beneficiary’s treatment related to the underlying claim.

Apr-Jun 2015 Issue

ISO Claims Partners