Benefits Coordination and Recovery Center (BCRC) Overview

Agenda BCRC Responsibilities BCRC processes Overview of Data Collections process Overview of Recovery process BCRC Contact Info Call Center IVR Tips Virtual Hold Benefits of BCRC Questions

BCRC Responsibilities Determining who pays Medicare claims first Ensuring claims are paid correctly Sharing Medicare eligibility data with other primary payers Avoiding duplicate payments Sending claims data to other insurers Recover when other insurance should pay first Purpose of program is to identify health coverage available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken Medicare benefit payments. Ensure claims are paid correctly, and ensuring the primary payer – Medicare or other insurance – pays first Sending claims to supplemental insurers for secondary payment (Called “Crossover”) – agreement must be in place between the carrier and insurance company for COB to be automatic – beneficiary must have their supplemental insurance arrange crossover. If no agreement in place – then beneficiary required to coordinate secondary payments with any other insurers. Making sure that the amount paid in dual coverage situations does not exceed 100% of total claim.

How it works BCRC Data Collections Recovery Center Collects information from multiple sources to research MSP situation. Section 111 Mandatory Insurer Reporting submissions; Workers Compensation; etc. Responsible for identifying and recovering Medicare payments that should have been paid by another entity as the primary payer

Overview of the Data Collections Process

How Does BCRC Collect Information? Self Report (Call, Fax, Mail) Attorney, Beneficiary, Insurer, Provider, etc. Medicare Secondary Payer (MSP) Claims Investigations Prescription Drug Coverage Questionnaire Data Sharing Agreements (DSA) DSA – Data Sharing Agreement COBA – Coordination of Benefits Agreement Mandatory Insurance Reporting (Section 111) IEQ – Used to collect information about health care coverage that should pay hospital or medical bills before Medicare. Beneficiaries are sent the IEQ approximately 3 before they are entitled to Medicare. IRS/SSA/CMS Data Match Project – in 1989 Congress enacted a law (Section 6202 of the Omnibus Budget Reconciliation Act of 1989) to provide the Centers for Medicare and Medicaid Services (CMS) with better information about Medicare beneficiaries’ group health plan (GHP) coverage. The law requires that the IRS/SSA and CMS share information that each agency has about whether Medicare beneficiaries or their spouses are working. This is called Data Match. Under the law, employers are required to complete a questionnaire that requests group health plan (GHP) information on identified workers who are either entitled to Medicare or married to a Medicare beneficiary. MSP Investigations – Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not the responsible for paying first. MSP is sometimes confused with Medicare Supplement. A Medicare Supplement (Medigap) policy is private health insurance policy designed to specifically fill in some of the “gaps” in Medicare coverage when Medicare is primary. Medicare supplemental policies usually typically pay for expenses that Medicare does not pay due to deductibles or, co-insurance amounts or other limits under the Medicare Program. This MSP Claims investigation activity involves the collection of data on other health insurance that may be primary to Medicare based on information submitted on a medical claim or from other sources. VDSA – Voluntary agreements allow for the electronic data exchange of GHP eligibility and Medicare information between CMS and employers or various insurers.

Overview of the DC Process Beneficiary, Provider or Attorney calls to report a GHP, NGHP or request information on COB CSR asks probing questions to determine if beneficiary’s record is accurate

Overview of the DC Process Option 1 – Reporting new GHP record CSR collects information (SPD, 411.25 or PDC) In 24 to 48 hrs. CWF/HIMR system are updated Confirmation letter is sent to beneficiary

Overview of the DC Process Option 2 – Reporting new NGHP record CSR collects information (SPD, 411.25 or PDC) In 24 to 48 hrs. CWF/HIMR systems are updated Confirmation letter is sent to beneficiary

Overview of the DC Process Option 2 – Reporting new NGHP record cont. System forwards all NF and WC leads to CRC System receives electronic information and creates a Lead System forwards all Liability leads to BCRC

Overview of the Recovery Process

Recovery Process Hospital/doctor submits claim for payment This is an overview of the recovery process: A Medicare beneficiary is involved in an accident, incident or illness Medicare beneficiaries who are injured receive treatment. The providers will either bill the insurance and we will have no conditional payments to be refunded or they will bill Medicare if payment is not received promptly. Hospital/doctor submits claim for payment Accident/incident/ illness occurs Beneficiary goes to hospital/doctor

Recovery Process Medicare makes conditional payments for services Case is reported to BCRC and information is gathered MSP Recovery issues Rights and Responsibilities (RAR) Letter Medicare will pay the claim conditionally The incident will also have to be reported, either by self report or section 111 report Once the incident is reported it is fed from the COB to the Recovery wherein we issue a Right’s and Responsibilities (RAR) Letter to all parties on record who are affiliated with this claim. This letter basically puts the bene on notice that the incident was reported and walks them through their rights and responsibilities to reimburse Medicare. The payment is “conditional” because it must be repaid to Medicare if/when a settlement, judgment, award or other payment is secured

Recovery Process After issuing the RAR Letter, the search for all claims from the DOI begins Once all the claims are retrieved they are filtered through by an analyst to determine which claims are accident related and which claims are not and a CPL is issued. The CPL will notify the bene and any authorized entities to date how much money Medicare has paid. They will review this letter for accuracy and use it to negotiate their settlement. Medical claims related to the incident are identified and a Conditional Payment Letter (CPL) is issued The search for Medicare Claims begins Claims may be disputed from the CPL if recipient feels they are not accident related

Recovery Process Settlement, judgment, award, or other 10. Once a settlement has been reached the bene, or their representative, will submit settlement information (amount, date, fees and costs if applicable) 11. Upon receiving the NOS the Recovery Team will issue a final demand letter requesting payment be made within 60 days of the date of the demand. Settlement, judgment, award, or other payment is reached. Notice of Settlement (NOS) must be submitted to the BCRC The final payment amount is identified and a Demand Letter is sent

A check is received for demand amount Recovery Process Option 1 - Payment There are three possible responses to a demand letter. The first and most favorable is we received a check for the demand amount within the requested timeframe and the file will be closed. A check is received for demand amount MSP Case Complete

Recovery Process Option 2 – Issues Arise The second option is post demand correspondence such as: An Appeal- a disagreement with the existence of an overpayment of with claims on the demand Waiver- is their request for the entire debt to be forgiven A Compromise- is their request for a partial amount to be forgiven. A post demand inquiry is sent. (e.g. questions, appeals, request for waiver, etc.)

Recovery Process Option 3 – Intent To Refer If Full repayment is not received within 60 days of ITR Letter (120 days of demand), debt is referred to Treasury once any outstanding correspondence is worked Interest is assessed from date of demand if the debt is not resolved within 60 days The third and least favorable outcome to a demand is no payment or post demand correspondence is received. if payment is not received then interest will be assessed on the 61st day, and the interest is retroactive . This means that on the 61st day there will already be two months worth of interest on the debt. At that point we also have the ability to send an Intent to Refer (ITR) Letter which advises the debtor they are delinquent in reimbursing Medicare and we will turn the debt over to the Department of Treasury if payment is not forthcoming. If payment is still not received 60 days of ITR Letter (120 days of demand) then the debt is sent to Treasury once all correspondence has been finalized. If the debtor is the beneficiary then they risk having their social security or tax returns offset. If the debtor is the insurer then their Tax Identification Number (TIN) will be utilized in offsetting payments. If full repayment is not received within 60 days, an Intent to Refer Letter (ITR) is issued

Contact Information

Contact Information BCRC Area Address MSP Data Collection Data Collection Authorization Data Collections Authorizations PO Box 138898 Oklahoma City, OK 73113 Medicare MSP General Correspondence Medicare-MSP General Correspondence PO Box 138897 Oklahoma City, OK 73113 Medicare MSP Claims Investigation Project Medicare-MSP Claims Investigation Project Voluntary Data Sharing Agreement VDSA Program PO Box 660 New York, NY 10274 Workers Compensation Set Aside Arrangement Proposal WCMSA Proposal/Final Statement PO Box 138899 No change

Contact Information BCRC Area Address Recovery NGHP Inquiries/Checks/Recovery Authorizations NGHP PO Box 138832 Oklahoma City, OK 73113 Fixed Percent Option PO Box 138880 Special Projects (Product Liability Case inquiries and SP Checks) Special Projects PO Box 138868 Oklahoma City, OK 73116 Self Calculated Conditional Payment Option Self-Calculated Conditional Payment Overnight Mail – address requests, i.e. subpoenas, checks, etc . 7608 N. Hudson Ave Raster Master will be removed and only eave BCRC

IVR Tips 855-798-2627 First Menu Beneficiary- Press 1 Calling about Beneficiary- Press 2 Commercial Repayment Center- Press 4 Selection must be made at this menu before pressing “0” for an agent

IVR Tips Beneficiary Menu 800 Medicare transfer- Press 1 Otherwise Press 2 for BCRC Complete Authentication via speech recognition (4 pieces) Successful Authentication Presented Dynamic Menu based on information on Beneficiary File Unsuccessful Authentication Call is transferred to an agent

IVR Tips Other Caller Menu Provider- Press 1 RRE- Press 2 Attorney- Press 3 Agent, Other Rep- Press 4 Employer- Press 5 DSA- Press 6

IVR Tips Authentication will vary based on caller type For example Provider/RRE 2 pieces to identify entity 2 pieces for Beneficiary Successful Authentication Presented Dynamic Menu based on information on Beneficiary File Unsuccessful Authentication Call is transferred to an agent

Self Service Information Coverage Status Medicare Primary Versus Secondary Status on Specific Date Entitlement Information Date Reason ESRD Information Date of Dialysis Coordination Period Recovery Information RAR Date CPL Mail Date and Amount Demand Mail Date and Amount

Virtual Hold Call Center offers Virtual Hold Offers to call back while holding place in the queue Once called back, agent is ready to assist Saves time by not waiting on hold Enhances Customer Experience

How BCRC Benefits our Customers Enhanced Beneficiary experience because claims are processed with greater efficiency due to accurate records Timelier processing of beneficiaries’ medical claims reduces employers administrative expenses Physician and supplier’s payments increase when Medicare is secondary payer Reduces cost of recouping payments made in error and ensures integrity of Medicare Trust Fund

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