Medicare Introduces Self-Reporting


By Marty Cassavoy, VP of Medicare Secondary Payer Compliance Services

The holiday season is always a busy one for the Federal Medicare Secondary  Earlier today Medicare hosted a brief webinar outlining two enhancements to the Medicare Secondary Payer Recovery Portal (MSPRP).  If you blinked, you may have missed it, but the representative reading the presentation packed a ton of information into that 30 minute period.  Here are the key items that you need to know:

Direct Entry of “Leads” in the MSPRP

Beginning early next month MSPRP users will be allowed self-report workers’ compensation, no-fault and liability leads electronically via the MSPRP.  There are a few basic requirements that will limit the functionality of this program only to cases that could not or should not have previously been reported via section 111 reporting.  The parameters for self-reported “leads” are as follows:

  1.        The employer or insurer does not have ongoing responsibility for medical benefits (ORM) on the claim; and
  2.        A settlement has not previously been reported and/or consummated.

Both ongoing responsibility for medicals and settlements should be reported via section 111.  To the extent that either of those items has occurred, a self-report will not be possible.  However, if there is no ORM and if no settlement has previously been reported and/or consummated, than a self-report may be able to be made.  Importantly, at this point, if a lead has already been established by the BCRC then that information will be provided to the user and the user will be able to access the existing BCRC case that is already on file. When making a self-report, the individual making the report should be ready to include:

-          Identifying information for the injured party

-          Case specific information (i.e., date of incident, insurance type, etc.)

-          Injury information (i.e., ICD-9 or 10 codes or other injury description)

-          Claims payer information (i.e., the insurer or self-insured) including addresses

-          Attorney information, if the claimant is represented by counsel 

Once all of the information has been provided, a case will be set up by the Benefits Coordination and Recovery Contractor (BCRC) naming the Medicare beneficiary as the case debtor.  The information will be immediately accessible in the MSPRP and users will be able to upload information (authorizations, settlement information, etc.) y.  If no settlement information is provided, then a conditional payment letter will be mailed to the beneficiary and all authorized recipients.  If settlement information is provided, then a conditional payment notice will be provided to the beneficiary as well as authorized providers. 

The Interesting Details

A user has the opportunity to enter up to 25 injury codes per claimant.  This seems excessive and is greater even than the number of codes available in section 111 reporting.  If you are entering 25 codes, you are probably entering too many.  Second, these leads will only be set up for BCRC cases listing a beneficiary debtor. The typical case where this process would be employed would be a liability claim or a denied workers’ compensation claim.  In both such cases, no ORM will exist and the beneficiary will be named the debtor.  The same process is available for beneficiaries as well.  If a case exists, it will add the case to the user’s case listing it will redirect and allow the user to manage there

If no case exists, a case creation continue page will display and users will be able to add up to 25 diagnosis codes; users will have three options to enter the data; if you select by injury category, that will display.

The Bottom Line

This is yet another in a line of upgrades to the MSPRP designed to make it more user-friendly and self-service.  We appreciate the service is available, although it is limited only to cases where no ORM exists.  Every little bit helps!  ExamWorks Clinical Solutions will continue to monitor the updates to the MSPRP and will provide further information as warranted.

About Marty Cassavoy

Marty Cassavoy is the Vice President of MSP Compliance at ExamWorks Clinical Solutions.  Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer compliance and across all insurance types.  An attorney licensed to practice law in Massachusetts, Marty works out of ExamWorks’ Woburn, Massachusetts office and can be reached at 781-517-8085 or