The Health Insurance Portability and Accountability Act includes a provision establishing the Medicare Integrity Program (MIP). This provision gives the Centers for Medicare & Medicaid Services (CMS) authority to enter into contracts with entities to promote the integrity of the Medicare program. The MIP includes a range of Medicare program areas such as cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program.
Pursuant to the MIP authority, CMS awarded the Coordination of Benefits (COB) Contractor the responsibility for MSP activities. The COB Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. By law, when Medicare beneficiaries have certain private insurance, other insurers should pay first. The COB Contractor collects information on the proper order of payers, and ensures that Medicare makes primary payment only for those claims where it has primary responsibility. When mistaken Medicare primary payments are identified, recovery actions from other insurers are undertaken.
Federal law (42 USC 1395 y (b) establishes that Medicare is the secondary payer to workers' compensation (WC) and has a priority right of recovery over that of any other entity to the proceeds of any settlement of an individual's claim and a subrogation right. Beneficiaries are required to file for all workers' compensation benefits for which they can reasonably be expected to obtain compensation. The parties are required by statute and regulations to protect Medicare's interest when resolving WC cases, including both past and future medical payments. For more information regarding CMS' Workers' Compensation policy regarding future medical payments, click here. (See section 1862(b) of the Social Security Act/42 USC 1395y(b) and 42 CFR Part 411, including regulations in Subpart C specific to Workers' Compensation.) To avoid future overpayment negotiations and penalties, it is clearly in everyone's best interests, Medicare, the WC agencies, and the claimants - for all parties to work together.
WC Data Sharing Agreements
The CMS is currently in the process of identifying those states that are able to provide WC data to match with our Medicare eligible database. As a result, CMS will (1) identify those beneficiaries that may have been paid mistakenly by Medicare when WC should have been responsible for the claim payment and (2) avoid payment of a WC claim by annotating the beneficiary's record with accurate WC data related to a specific occurrence. The Privacy Act of 1974 (modified in 1990,) 5 U.S.C., Section 552a permits routine uses of records maintained in CMS systems of record for the initial or continued right to any benefit or payment, e.g., a State WC Board, for the purpose of coordination of benefits with the Medicare program and implementation of the Medicare Secondary Payer provisions at 42 U.S.C, 1395y(b).
The COB Contractor would like to work more closely and cooperatively with the WC agencies in properly coordinating payment responsibilities. We encourage WC agencies to contact the COB Contractor regarding utilizing data sharing agreements. Data sharing with WC agencies will benefit the Medicare program by identifying new cases that have gone undetected and by avoiding erroneous payments that would have been made under Medicare. Data sharing would involve routine downloads of WC agencies' databases which would be matched up against current Medicare beneficiaries' files to identify possible MSP occurrences. This would avoid Medicare making a mistaken payment and eliminate the need to recover from the WC carrier or responsible party.
The CMS and its partners would appreciate the opportunity to discuss details regarding the minimum data required and any suggestions or concerns you may have regarding a WC data match. This may be done initially through teleconferencing or a site visit to your offices. Please contact Donna Kettish, CMS Health Insurance Specialist, at 410-786-5462 or via e-mail at firstname.lastname@example.org to set up the initial meeting with CMS, the COB Contractor and Mr. Neil Hoosier.