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Briefing: Air Force Medical Affirmative Claims (MAC) Process-How Should MAC Work?

Briefing: Air Force Medical Affirmative Claims (MAC) Process-How Should MAC Work?. Date: 24 March 2010 Time: 1110-1200. Objectives. Today we will discuss: What is MAC? Responsibilities Key HSI Areas Training Medical Staff on Program Creating Bills Elements of a Successful MAC Program

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Briefing: Air Force Medical Affirmative Claims (MAC) Process-How Should MAC Work?

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  1. Briefing: Air Force Medical Affirmative Claims (MAC) Process-How Should MAC Work? Date: 24 March 2010 Time: 1110-1200

  2. Objectives Today we will discuss: • What is MAC? • Responsibilities • Key HSI Areas • Training Medical Staff on Program • Creating Bills • Elements of a Successful MAC Program • Legal Reorganization • Immediate Future of MAC

  3. What is MAC? What is Medical Affirmative Claims (MAC): • Program Outlined in DoD 6010.15, AFH 41-114, AFI 41-115, AFI 41-120, and AFI 51-502, Personnel and Government Recovery Claims (primarily SJA responsibility) • Dollars recouped from Liability insurances for retirees, family members, and AD who receive treatment at government expense as a result of injury (includes food poisoning) or illness sustained as a result of an injury • Dollars for MTF treatment deposited directly into MTF O&M-separate from TPC/MSA (sales code 94) • Civilian medical care costs deposited into General Treasury unless MTF pays for care

  4. What is MAC, Cont’d? What is MAC, Cont’d: • Types of Tort Insurance billed • Automobile • No-fault and/or Personal Injury Protection (PIP) • Boat and Airplane • Products and/or Manufacturer’s • Premises • General Casualty (slip/fall) or Umbrella (covers a variety of personal properties) • Homeowners’ and/or Renter’s • Medical Malpractice (other than Federal)

  5. Responsibilities Yours and SJA Responsibilities: • Have a written MOA between MTF and SJA outlines notification, preparation, and follow-up procedures (overseas only) • Stateside bases no longer need an MOA between MTF and SJA!! SG and SJA now have a MOA for all MTFs • MTF provides updated fund cite to SJA at FY start • MTF identifies all injuries to base SJA using the AF 1488, Daily Log of Patients Treated for Injuries • Other options may be MAJCOM or base safety form (still needs to be transferred by MAC Clerk to 1488) • SJA determines if injury and subsequent treatment represents a potential recoverable claim, and pursues payment pursuant to the Federal Medical Care Recovery Act

  6. Responsibilities Yours and SJA, Cont’d Responsibilities Cont’d: • MTF prepares AF 438, Medical Care-Third Party Liability • MTF provides billing rates • Rates available on UBO website by locality code • FY09-Rates for Inpatient • Current rates for Outpatient • Current rates for Pharmacy • MTF provides a quick response to all SJA medical record documentation requests/SJA mails claim

  7. Responsibilities Yours and SJA, Cont’d Responsibilities Cont’d: • MTF and SJA reconciliation of open, transferred, and closed claims • Although guidance states quarterly; do this monthly now that all Legal regions are open • Money will be deposited by the SJA • Verification during reconciliation process • Ensure accounting system accurately records deposits

  8. Key HSI Areas Important HSI Areas as provided by recently inspected MTFs: • Need separate TPC MOA • Inspector will ask to see that you have the MOA for MAC, but they also expect to see a separate one for TPC • If your local legal office will NOT sign an MOA for TPC then the inspector will ask to see documentation between legal and MTF • Inspectors will not pass this area if you do not have one signed, even if you have paperwork showing that legal has rejected MOA. We suggest that you get your chain of command involved because this will reflect negatively on your inspection

  9. Key HSI Areas, Cont’d • Make sure that all quarterly reconciliations are documented • If a region or local legal office will not comply, inspector needs to see all documentation between legal and MTF • Again inspectors will fail this area if reconciliations are not complete. Please get your chain of command involved • Quarterly TPC training for ALL points of entry in clinics • Inspectors like to see signed sheets for attendees and see actual training documentation • Inspectors like to see the completed 1488s, however they also are aware of the MAC Enhancement Tool • Learn how to print this out and keep it with the 1488s to verify that all injuries are being logged

  10. Train Your Staff Training Medical Staff: • You are responsible for ensuring that all clinic personnel are properly trained regarding the identification of potential MAC cases • Set up a training plan to include: • Regularly scheduled training sessions at least quarterly to include- providers, nurses, technicians, records clerk, and admin staff • Initial training for all incoming personnel • This area is part of HSI

  11. How to Create Bills Creating Bills: • No Standard System • Air Force is working on a universal billing system for MAC • Billing methods currently available are: • Submit bills to SJA on AF Form 438 • If this is working for your MTF then continue with this process • Use TPOCS Read only access and manually complete billing forms on typewriter • UB-04 • CMS 1500

  12. UB-04

  13. New CMS 1500

  14. How to have a successful Program Elements of a Successful MAC Program: • Cooperative relationship between legal and medical staff • Timely identification/notification of possible MAC cases • Process organized and understood throughout the facility • Audit procedures (at least monthly) • With legal staff (open/closed MAC cases) • With Medical staff (to ensure clinics are catching potential MAC cases) • Training medical staff/clinics on MAC

  15. MAC Enhancement Tool Elements of a Successful MAC Program Cont’d: • Understand the MAC Enhancement Tool • Change Package (279-281) released on 3 Nov 05 (CHCS administrator must issue security keys) • New fields/functionality • Injury/Accident related indicator • Date/Place of Injury/Accident • Injury case codes • Identify possible liability cases • Capture, store, and link specific clinical data/medical codes related to injury and accident information • Ability to generate reports

  16. Menu Path MAC Enhancement Tool Menu Path For MAC Enhancement Tool: • This should be reviewed weekly and put on a 1488 and then sent to legal for review • Each clinic needs to know how to use this, but recommend that they either use 1488 OR MAC Enhancement Tool • When an appointment is booked, an automatic question will pop up “Is this related to an accident?” It is defaulted to “NO”, so clinic must change to “YES” if appropriate • Menu Path: • ADM Ambulatory Data Module • Ambulatory Data Reports >2 • MAC Medical Affirmative Claims SVS Reports • If you do NOT have access to ADM you will need to see your CHCS manager

  17. MCRP Regions Wright-Patterson AFB, OH McGuire AFB, NJ Travis AFB, CA Offutt AFB, NE Nellis AFB, NV Langley AFB, VA Eglin AFB, FL Lackland AFB, TX

  18. Proposed Internal Structure(Notional) Region 2 – Langley GS-13 Attorney (Plus Region 1) GS11/12 Supervisor (1) GS-9 Senior Paralegal (1) GS-7/8 Mid-Level Paralegal (4) GS-5/6 Entry Paralegal (1) Bases: Arnold, Charleston, Langley, Pope, Seymour Johnson, Shaw States: VA, NC, SC, TN, WV Region 1 – McGuire GS11/12 Supervisor (1) GS-9 Senior Paralegal (1) GS-7/8 Mid-Level Paralegal (2) GS-5/6 Entry Paralegal (1) Bases: Andrews, Bolling, Dover, Hanscom, McGuire, Rome Lab States: MD, DE, NJ, CT, RI, PA, NY, MA, VT, NH, ME Region 4 – Wright-Patterson GS-13 Attorney (Plus Region 3) GS11/12 Supervisor (1) GS-9 Senior Paralegal (1) GS-7/8 Mid-Level Paralegal (2) GS-5/6 Entry Paralegal (2) Bases: Scott, Whiteman, Wright-Patterson States: KY, IN, OH, WI,.IL, MO, MN Region 3 – Eglin GS11/12 Supervisor (1) GS-9 Senior Paralegal (2) GS-7/8 Mid-Level Paralegal (4) GS-5/6 Entry Paralegal (2) Bases: Columbus, Eglin, Hurlburt, Keesler, MacDill, Maxwell, Moody, Patrick, Robins, Tyndall States: AL, GA, FL, MS Region 5 - Lackland GS11/12 Supervisor (1) GS-9 Senior Paralegal (2) GS-7/8 Mid-Level Paralegal (4) GS-5/6 Entry Paralegal (1) Bases: Altus, Barksdale, Brooks, Dyess, Goodfellow, Lackland, Laughlin, LittleRock, Randolph, Sheppard, Tinker, Vance States: AR, LA, OK, TX Region 6 – Offutt GS-13 Attorney (Plus Region 5) GS11/12 Supervisor (1) GS-9 Senior Paralegal (1) GS-7/8 Mid-Level Paralegal (3) GS-5/6 Entry Paralegal (1) Bases: Ellsworths, F.E. Warren, Grand Forks, Malmstrom, McConnell, Minot, Offutt States: NE, IO, ND, SD, MT, WY, KS Region 7 – Nellis GS11/12 Supervisor (1) GS-9 Senior Paralegal (1) GS-7/8 Mid-Level Paralegal (4) GS-5/6 Entry Paralegal (2) Bases: Academy, Buckley, Cannon, Davis-Monthan, Hill, Holloman, Kirtland, Luke, Nellis, Peterson States: NV, CO, NM, AZ, UT Region 8 - Travis GS-13 Attorney (Plus Region 7) GS11/12 Supervisor (1) GS-9 Senior Paralegal (1) GS-7/8 Mid-Level Paralegal (4) GS-5/6 Entry Paralegal (2) Bases: Beale, Edwards, Eielson, Elmendorf, Guam, Fairchild, Hickam, LA, McChord, Mountain Home, Travis, Vandenberg, States: AK, CA, HI, OR, WA, ID

  19. Immediate Future of MAC FUTURE of Air Force MAC: • Air Staff is still working on universal billing system that will have a tracking database and will print billing forms • New MOA is being negotiated by Air Staff • All regions are now open • Contact regional manager to discuss new process if any • Slide 18 has contact information to all Regional Managers • We expect MTFs to scan or fax all claim packages to their regional office (encrypted) • MTFs need to keep track of cases at legal • E-mail MAJCOM Manager for generalized excel sheet • Accounting system information used to pay legal

  20. Review Time Lets Review: • What is MAC? • Responsibilities • Key HSI Areas • Training Medical Staff on Program • Creating Bills • Elements of a Successful MAC Program • Legal Reorganization • Immediate Future of MAC

  21. Quiz Questions: • What rates do we use for inpatient? • What rates do we use for outpatient? • Who is responsibly for training MTF staff on the MAC Program? • How can you do this? • How do we log injuries? • Does MTF or Legal deposit funds collected? • Where can you find rates for MAC?

  22. Q&A QUESTIONS????

  23. References • AFI 41-114, Medical Health Service System Matrix • Determines eligibility and appropriate charges for health care • AFI 41-115, Authorized Health Care and Health Care Benefits in the Military Health Services System (MHSS) • Determines eligibility for health care, health care benefits, and extent of care that the AF authorizes (Civilian Employees) • AFI 41-120, Medical Resource Management Operations • Guidelines for RM or UBO Flight commanders in MTFs • DoD 6010.15, Military Treatment Facility Uniformed Business Office Manual • Guidelines for operations of MTF business offices. Prescribes procedures and accounting systems for management of accounts and TPC activities • AFI 51-502, Personnel and Government Recovery Claims (SJA)

  24. Websites • http://www.tricare.mil/ocfo/mcfs/ubo/index.cfm • UBO Website • http://www.dtic.mil/comptroller/ratesindex2002.html • Rates

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