Briefing: Basic Army MAC Billing Date: 21 March 2007 Time: 1010 - 1100

1. Briefing: Basic Army MAC Billing Date: 21 March 2007 Time: 1010 - 1100

2. Objectives • Understand the legal basis for the Government’s right to recover under the MAC program • Understand how FMCRA and 10 USC 1095 work together • Understand respective responsibilities of MTF and JAG office in MAC program • Billing for MAC claims • Understand benefits of the MAC program

3. Outline • The legal foundations of the MAC program • Federal Medical Care Recovery Act, 42 USC 2651-53 • 10 USC 1095 and 1095b • State law • Working with the JAG office • Responsibilities under the MAC Program • Concurrent MAC/TPCP claims • Billing for MAC claims • Benefits of the MAC program • Info on past collections • Where the money goes

4. Legal Foundations of MAC Program • Federal Medical Care Recovery Act, 42 USC 2651-53 • Gives Government the right to recover medical expenses and, for soldiers, lost pay • From the person liable in tort, or his insurer • Recovery depends on the existence of tort liability … someone must be at fault for the injury/illness for which the beneficiary receives medical care • Examples: • Negligence generally • Auto accidents • Slip-and-fall cases • Medical malpractice • Assault and battery

5. Legal Foundations of MAC Program Federal Medical Care Recovery Act, 42 USC 2651-53 (cont’d) Title 42 – The Public Health and Welfare • FMCRA applies to medical expenses for care furnished or paid for by the United States • We can recover for both MTF care and TRICARE • VA and Public Health Service also use it to recover medical expenses • Authority to set billing rates is delegated to the Office of Management and Budget (OMB)

6. Legal Foundations of MAC Program Federal Medical Care Recovery Act, 42 USC 2651-53 (cont’d) • Most FMCRA recoveries come from automobile liability insurance for auto accidents • Auto insurance policies primarily provide the insured with liability coverage to compensateothers injured by the negligence of the insured • Auto insurers also provide “first party” insurance to compensate the insured • Medical Payments • Personal Injury Protection (“PIP”) • Uninsured/Underinsured Motorist

7. Legal Foundations of MAC Program Federal Medical Care Recovery Act, 42 USC 2651-53 (cont’d) • Under FMCRA, we recover from the person at fault or his from his liability insurance • We do not recover “first party” or “no-fault” insurance under FMCRA • Medical payments and PIP coverage do not depend on fault • Uninsured/Underinsured motorist coverage depends on fault, but authority to recover derives from 10 USC 1095

8. Legal Foundations of MAC Program 10 U.S.C. 1095 • Gives the United States the right collect medical expenses from third party payers • “Third party” includes automobile liability insurance or no fault insurance carriers • Specifically includes PIP and Medical Payments • Also includes Uninsured/Underinsured Motorist

9. Legal Foundations of MAC Program 10 U.S.C. 1095 (cont’d) • 1095 itself is limited to expenses for MTF care 10 U.S.C. 1095b • Allows TRICARE to pay first even though third party payer (e.g., auto insurer) may be primary payer • Requires third party payers to reimburse United States for TRICARE costs • Right to collect is otherwise the same as under 10 U.S.C. 1095 (PIP, Med Pay, Uninsured/Underinsured motorist …)

10. Legal Foundations of MAC Program 10 U.S.C. 1095 & 1095b • Title 10 – Armed Forces • Authority to set billing rates delegated to DOD

11. Legal Foundations of MAC Program In addition to auto insurance: • Homeowners’ and renters’ insurance May provide liability coverage for bodily injury from which we can recover under FMCRA, and no-fault medical coverage, from which we can recover under 10 USC 1095 and 1095b • Professional liability insurance E.g., for medical malpractice – FMCRA • Products liability E.g., Airbag injuries or failure to deploy – FMCRA

12. Legal Foundations of MAC Program State Law • U.S. may have right to recover • As third party beneficiary to an insurance contract • Under State Workers Compensation statute • Under State law of subrogation

13. Working with the JAG Office Billing for MAC Claims • FMCRA (Title 42) OMB has not published billing rates for medical care recoveries under FMCRA since 31 October 2003 (68 Federal Register 62104) Rates “… will remain in effect until further notice.” • 10 USC 1095 and 1095b (Title 10) DOD has published updated billing rates since that time • Result: Different billing rates apply depending on whether the claim is made under FMCRA or Title 10

14. Working with the JAG Office RJA Responsibilities • Assert, compromise, waive, settle claims • Contact the MTF and TRICARE to ensure all amounts paid by the Government are included in claim before settlement • Tracking & Reporting • Provide MTF copies of MAC deposit vouchers for collections deposited to MTF O&M account, or a monthly report with pertinent patient info & amounts deposited • Provide MTF monthly list of claims closed without recovery or transferred to another jurisdiction during the month • Local RJA is not responsible for tracking claims or deposit of money as a result of claims asserted and/or collected by other RJA offices

15. Working with the JAG Office RJA Responsibilities (cont’d) • Identification of claims • Review civilian police accident reports, military police blotters, news reports, court proceedings, LOD investigations, and similar sources to extent possible to identify other potential MAC claims

16. Working with the JAG Office MTF Responsibilities • Make records availableto RJA Including electronic records, for identifying, asserting, and collecting claims • Ask patients how, when, where injuries occurred Use existing TPC program procedures and documents to the greatest extent possible to ensure accident and injury information is obtained (1) at point of entry, (2) during inpatient stay, (3) at discharge, and (4) by follow-up conversations with patient and family • Notify RJA Inpatient care – forward DA Form 2985 to RJA within 3 working days of admission for determination of potential claim. Record accident info (how, when, where) in section “FOR LOCAL USE” Outpatient care – RJA and MTF implement procedures to ensure outpatient records and documentation (ER logs, PT records, etc.) are screened for vehicle accidents, slip and fall, job-related injuries, product or equipment malfunctions, medical malpractice by civilian provider

17. Working with the JAG Office Shared RJA-MTF Responsibilities • Coordinate to ensure medical records are screened to identify potential MAC claims • Coordinate to screen requests for information from third parties to identify potential claims

18. Working with the JAG Office Concurrent MAC/TPCP Claims • Beneficiary may be covered by health benefits insurance and another type of insurance, such as automobile insurance • Government may not collect more than the cost of the medical care it provided from any one source or combination of sources

19. Working with the JAG Office Concurrent MAC/TPCP Claims • Establish procedures to facilitate sharing of information with RJA regarding MAC/TPCP claims and ensure coordination on any payments or denials • MTF will simultaneously: • File the MTFs TPCP claim • Notify the RJA of the MTF’s concurrent TPCP claim • Provide RJA information regarding MAC claim

20. Working with the JAG Office Concurrent MAC/TPCP Claims • DON’T postpone notifying the RJA until the TPCP claim is collected – doing so may prevent timely investigation and assertion of the MAC claim • Note: For job-related injuries, do not file TPC claim for care provided to beneficiaries who are non-federal employees or contractors if the beneficiary is covered by workers’ compensation benefits. Such claims fall under the MAC program and the claim is filed by the RJA

21. Benefits of the MAC Program • Amounts collected for MTF care are deposited directly to MTF O&M account • Available as part of the MTF budget for FY in which the collection is made • Can be used for renovation projects, medical equipment, computers, bonuses, etc. • Returns lost pay to unit of soldier who was unable to work due to injury • Returns money to TRICARE to be used to fund care to beneficiaries in the civilian network

22. Benefits of the MAC Program For FY 06 Number of claims asserted 14,515 Total $ asserted $32,457,983 Number recovered 12,754 Total $ recovered $16,214,647 MTF deposits $8,972,033 TRICARE deposits $6,947,224 Lost pay to units $295,391

23. Quiz • True or False: Bills for MAC claims are calculated using only billing rates set by OMB • True or False: The RJA should be notified of a potential MAC claim only after the TPC claim has been paid