This week, the Centers for Medicare and Medicaid Services (CMS) released version 7.3 of their Non-Group Health Plan (NGHP) User Guide with a few modifications. The most significant modification is clarification of triggers for “ongoing responsibility for medicals” (ORM).
Background
CMS and the Section 111 Mandatory Insurer Reporting / Medicare Secondary Payer stakeholder community have been in conversation as of late about ambiguous ORM guidance / interpretation and the unintended consequences / downstream impact on beneficiaries and responsible reporting entities (RREs), respectively. Please recall CMS tweaked ORM trigger language a bit when they released version 7.2 in June of this year, which we addressed a prior blog. The version 7.2 ORM trigger language read as follows:
“The trigger for reporting ORM is the assumption of ORM by the RRE, which is when the RRE has made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness. Medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM reporting to be required. The effective date for ORM is the [date of injury (DOI)], regardless of when the beneficiary receives the first medical treatment or when ORM is reported.”
The Change
As a direct result of continuing efforts between CMS and the stakeholder community, CMS issued the following clarification this week:
“The trigger for reporting ORM is the determination to assume ORM by the RRE, which is when the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving) medical treatment related to the injury or illness sustained. Required reporting of ORM by the RRE does not necessarily require the RRE to have made payment for Medicare-covered items or services when the RRE assumed ORM, nor does a provider or supplier necessarily have to have submitted a claim for such items or services to the RRE for the RRE to assume ORM. The effective date of ORM is the DOI, regardless of when the beneficiary receives the first medical treatment or when ORM is reported.” (new language in bold)
Meaning and Impact
As discussed in our June blog, continuing clarification around ORM is welcome because it reinforces that an injured party must actually receive medical treatment in order for ORM reporting to be required, and now normal due diligence (i.e. no special extra claims handling effort) is the standard to which a carrier / self-insured must adhere when it comes to learning / verifying whether medical treatment is occurring or has occurred. This clarification continues to be of significant value to no-fault carriers / self-insureds when they learn of a minor accident where no medical treatment is sought by the injured party.
ECS monitors Section 111 Mandatory Insurer Reporting and Medicare Secondary Payer matters closely; we will certainly continue keep you apprised of additional developments around ORM triggers in future. Should you have any questions about ECS’ Section 111 reporting services or how policy changes and clarifications impact your claims, please contact Annie Davidson at 651-26-9618 or annie.davidson@examworkscompliance.com.