To dial into the audio bridge : 1-408-600-3600 Event ID: 666 375 908

1. To dial into the audio bridge: 1-408-600-3600 Event ID: 666 375 908 Welcome Ease Your Medicare Compliance Pains with Automated Information Controls The webinar will begin shortly.

2. Speaker Introduction • Jennifer S. Burke • Partner, CassidaySchade, LLP • Practice focused in the representation and counsel of employers in workers’ compensation and Medicare Set-Aside matters • Frequent author/speaker and member of the Illinois State Bar Association, the Workers’ Compensation Lawyer’s Association, the Illinois Association of Defense and Trial Counsel, and the National Alliance of Medicare Set Aside Professionals. • Dan Dopp • Leader Customer Acquisition Group • Over 15 years experience in Control Automation and Continuous Monitoring • Recognized expert and thought leader in Automated Controls Jennifer S. Burke Dan Dopp

3. Agenda Medicare Secondary Payer Act Who is impacted Typical Medical Reporting Scenario Automated Controls: Information Controls Framework Best Practices Going Forward

4. www.cassiday.com Ease Your Medicare Compliance Pains with Automated Controls Presented by: Jennifer S. Burke, Partner • Chicago • Libertyville • Naperville • Rockford • Chesterton

5. Medicare Secondary Payer Act • 42 U.S.C. 1395y(b)(2)(A)(ii) Medicare is precluded from paying medical expenses to the extent that payment has been made or can reasonably be expected to be made under a workers’ compensation law or plan or under an automobile or general liability insurance policy or plan or under no-fault insurance. Became law December 5, 1980

6. Section 111 of the MMSEA(Medicare, Medicaid and SCHIP Extension Act of 2007) • Requires any entity making a payment to a Medicare beneficiary to report that payment to CMS • Signed into law December 29, 2007 as an amendment to the Medicare Secondary Payer Act • This will be the method by which CMS red flags any case in which they might be entitled to a recovery of medical payments

7. MMSEA, 42 U.S.C. 1395y(b)(8) • WHO: Applicable plans must report • Applicable plans are defined as: • Liability insurance, including self-insurance • No fault insurance • Workers’ compensation laws or plans

8. WHAT: Report the identity of a Medicare beneficiary whose illness, injury, incident, or accident was at issue as well as such other information specified by the Secretary to enable an appropriate determination concerning coordination of benefits, including any applicable recovery claim.

9. WHEN: In a form and manner specified by the Secretary • Information shall be submitted within a time specified by the Secretary after the claim is resolved through a settlement, judgment, award or other payment (regardless of whether or not there is a determination or admission of liability) • Submissions will be in electronic format

10. Further Defining “Who” • REQUIRED REPORTING ENTITIES (RREs) • Generally the insurer is the RRE • TPAs in a non-group health plan (NGHP) are never RREs based solely on their TPA status • In cases involving multiple defendants you will likely have multiple RREs and thus multiple reports • Can usually follow the responsibility for the payment to determine the RRE • For further information regarding issues pertaining to SIRs, deductibles, bankruptcy, acquisitions, foreign insurers, insurance pools see the MMSEA User Guide, Version 3.1

11. Further Defining “What” • The Medicare beneficiary… • 65 years of age • Receipt of Social Security Disability Insurance Benefits for 24 months • End stage Renal disease • All of these should be red flags for you when determining which cases need to be reported.

12. Have your attorney or claims representative ask Medicare beneficiary questions in written and oral discovery • Provide the claimant with CMS’ model language on a yearly basis: www.cms.gov/MandatoryInsRep/Downloads/NGHHICNSSNNGHPForm.pdf • Use the Query function • Document your efforts

13. Defining an internal process for identifying Medicare beneficiaries and securing the necessary information to enable you to report is critical to compliance and avoiding liabilities associated with non-compliance.

14. Reports must be made without regard to liability. Any payment must be reported, within certain thresholds • “Payment” is not limited to cash compensation. Anything of monetary value can be considered payment

15. Further Defining “When” • No-Fault Insurance • There is NOde minimis dollar threshold for reporting the assumption/establishment of ORM or for reporting TPOC • Liability Insurance ORM • There is NOde minimis dollar threshold for reporting the assumption/establishment of ORM

16. Workers’ Compensation ORM • Claims meeting all of the following criteria are excluded from reporting for submissions through December 31, 2011 • The claim is for “medical only” and • The “lost time” for the worker is no more than the number of days permitted by the applicable workers’ compensation law for a “medical only” claim or seven calendar days if the law has no such limit and • All payment(s) has/have been made directly to the medical provider and • Total payment for medicals does not exceed $750.00

17. Liability Insurance and Workers’ Compensation TPOC Amounts • Requirements: • TPOC thresholds do not apply to reported ORMs. If a case with a reported ORM is under threshold it is reportable at the RRE’s discretion. If over the threshold, it must be reported • TPOC checks will apply only to add records • Add records which have no ORM and do not meet the total TPOC threshold will be rejected with an error code • In the case of multiple TPOCs associated with the same claim record, the combined, cumulative TPOC amounts must be considered in determining whether or not the reporting threshold is met. However, multiple TPOCs must report in separate TPOC fields

18. Only TPOC dates of 10/1/2010 and subsequent need be reported. Prior dates are at the RRE’s discretion • The threshold dollar and date ranges apply to the date when the threshold is met (the most recent TPOC date). Timeliness of reports will be determined based upon the applicable date for the TPOC which caused the threshold to be met • For TPOCs involving a deductible, where the RRE is responsible for reporting both any deductible and any amount above the deductible, the TPOC amount includes the total of these two figures which in turn is included in the total TPOC amount used for the threshold check

19. Dollar and Date Thresholds • Claims where the last TPOC is prior to January 1, 2012 with TPOC totaling $0.00 - $5,000.00 are exempt • Claims where the last TPOC date is January 1, 2012 through December 31, 2012 with TPOC amounts totaling $0.00 - $2,000.00 are exempt • Claims where the last TPOC date is January 1, 2013 through December 31, 2013 with TPOC amounts totaling $0.00 - $600.00 are exempt • No threshold applies to claims where the last TPOC date is subsequent to January 1, 2014

20. Time Frames • Data collection should have already begun. Your first report will include any items settled on or after 10/1/2010 • If you registered, you were assigned a submission timeframe for the first quarter of 2011. Your report must be submitted properly in that window to be considered timely • Reporting will continue on a quarterly basis thereafter assuming you have claims to report • Use the EDI Representative assigned to you at registration. They are there to help you through the process. Communication is key! • If you have not registered but expect to have something to report, you need to register with enough time to allow for a test submission prior to the actual report

21. ENFORCEMENT • 42 U.S.C. 1395y(b)(8)(E) • A applicable plan that fails to comply with the requirements under subparagraph (A) with respect to any claimant shall be subject to a civil money penalty of $1000.00 for each day of noncompliance with respect to each claimant.… A civil money penalty under this clause shall be in addition to any other penalties prescribed by law and in addition to any Medicare secondary payer claim under this title with respect to an individual.

22. Typical Medicare Reporting Scenario • Information prepared for CMS reporting must be aggregated from multiple systems across multiple platforms • Information must be validated for completeness and reasonability, in addition to being transformed into the acceptable CMS universal format • Gateway filters out transactions that do not meet CMS data quality criteria. • Responsibility rests with the reporting entity to record and resubmit

23. Data (CMS Format) Typical Medicare Reporting Scenario Claim System #1 CMS Claim System #2 Gateway Claim Sys tem #3 Claim System #4

24. Medicare Reporting Challenges Multiple Systems Multiple Platforms and Data Formats Batch and Real time source systems Error Monitoring Changes in Source Systems Changes in Reporting Requirements

25. Typical Business Problems • Reportable claims are lost in process and run the risk of generating fines • Information is incomplete/does not meet CMS requirements • Exceptions are not documented and are managed ineffectively • On going changes to CMS data elements requirements are not implemented • Duplicate/Missing information submitted

26. Current Approach to Address Challenges Manual Balancing of information sent to CMS Logging activity into spreadsheets Email based exception management processes Embedded hard coded application controls Limited or Lack of Audit Trail

27. Information Controls Framework:Automated Controls • Information sent to CMS reconciles with originating source systems • Claimant data sent is complete and consistent to Mandatory Insurer Reporting Requirements • Centralized management of all claims exceptions pending delivery to CMS • Error trending to increase operational efficiency • Visibility and continuous monitoring information sent to CMS • Information is not duplicate and is reasonable

28. Data (CMS Format) Information Controls Framework Claim System #1 CMS Claims System #2 Gateway Claim System #3 Claim System #4

29. Information Controls Framework:Automated Information Controls End-to-End Integrity

30. Information Controls Framework: Visibility - Controls Monitoring 30

31. Information Controls Framework: Visibility - Operational Intelligence 31

32. Benefits of Automated Controls Avoid unnecessary fines by confirming all required claims are sent to CMS Verify each claim contains complete and accurate information as directed by CMS Reduce the Cost of MSP Compliance Increase visibility into Medicare Compliance process Be prepared for CMS reporting changes and requirements

33. Best Practices Game Plan • Assess Risk • Define/Design appropriate Controls • Define Continuous Monitoring Needs • Implement & Test • Extend control best practices outside of MSP

34. Q&A

35. Thank you for participating! For more information, please visit us at: http://www.cassiday.com For more information, please visit us at: http://www.infogix.com • An archive of this event will be made available on the Infogix website shortly. Any questions that were received but not answered during the live broadcast will be answered via email. Company, product, brand, and mark names and logos herein are the property of their respective owners. For a list of Infogix trademarks, visit: www.infogix.com/legal