Ventiv Technology

The Essential Guide to Claims Technology in a Changing Environment 17 C H A P T E R 6 : R E G U L AT O R Y C O N S I D E R AT I O N S CMS Reporting Challenges Centers for Medicare & Medicaid Services (CMS) reporting is a challenge for many claim organizations. The federal mandate requires claim organizations to disclose any payments made to Medicare-eligible beneficiaries. While Medicare would cover the initial cost of the patient's treatment, the insurer would be the "primary" payer and ultimately responsible for the costs. The inability to efficiently seek reimbursement from insurers resulted in the CMS reporting model, also known as the MMSEA Section 111, in 2007 in an attempt to reduce unnecessary Medicare costs. Due to the infrequency of Medicare-eligible beneficiaries, CMS reporting is not a day-to-day occurrence. This presents a challenge for claim organizations, as adjusters need to identify these claims as they arise and take appropriate steps. Examiners need to be knowledgeable, proactive, and quick to respond, as there are strict penalties for non-compliance, including fines of $1,000 a day per claim. Organizations need to deliver accurate data in a timely fashion to avoid strict penalties. While some organizations choose to do it all manually, new technology is drastically improving the efficiency of CMS reporting. Keeping up With State Mandates Each state typically has its own regulatory agency or board when it comes to workers compensation, which means that mandates vary state by state. Claim organizations must meet each state's requirements from jurisdictional forms to disability rates and even EDI reporting for states that have adopted the IAIABC's national standards. For many large claim organizations that operate across multiple state lines, it can be a considerable task to track and comply with the stringent requirements. Jurisdictional Forms There are thousands of forms across all jurisdictions that organizations are expected to file and submit at different points along the claims process. Deadlines differ depending on form and state, and with continual document updates, it can prove extremely challenging for organizations to manage. Automation in the form of technology is essential to keeping insurers compliant. Current systems integrate all state-mandated letters, forms, and reports into the application. Updates are managed by the vendor and pushed out in a timely fashion, reducing an organization's exposure to fines and providing peace of mind. Benefit Rates Payments made to injured workers differ state-by-state. The calculations are often complex, and the rates are frequently updated, meaning organizations need to maintain accuracy, update systems, and react in a timely manner. Utilizing current technology can ensure claim organizations keep up state-specific rate changes without compromising the efficiency of the workflow. EDI Reporting EDI reporting in the workers' compensation industry is beginning to build traction. More states are adopting the IAIABC's electronic reporting of FROI (first report of injury) and SROI (subsequent report of injury), and with it, comes a range of challenges. While the IAIABC sets the standard, each state has its own rules and regulations regarding the timing and sequence of submissions. Incorrect transmissions can result in delays, re-submission of claims and substantial fines for organizations. Also, as confidential information is being shared, organizations need to ensure proper steps are taken to safeguard and encrypt data.

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