Insurance adjusters throughout the country should already be aware of MMSEA Section 111, which mandates that insurance companies submit electronic reports with information about payments made to Medicare beneficiaries by liability insurers, no-fault insurers, workers’ compensation insurers, and even self-insurers.
These reporting requirements only apply to payments to Medicare beneficiaries. But the new rules affect all claims because a threshold question for each and every liability or no-fault claim will be: Is the claimant a Medicare beneficiary?
Some claimants may admit that they are Medicare beneficiaries. But for any claimants that deny they are Medicare beneficiaries, insurers have a duty to investigate whether those claimants actually are Medicare beneficiaries. And for any claimants who admit to Medicare beneficiary status but provide inaccurate Medicare Health Insurance Claim Numbers (HICNs), the insurer must determine the correct number.
CMS (Centers for Medicare and Medicaid Services) has created an electronic query program for insurance companies to use to determine the Medicare status of beneficiaries. For a successful query, the insurer needs:
- the claimant’s Social Security Number (or preferably the claimant’s HICN),
- the claimant’s date of birth,
- the claimant’s name, and
- the claimant’s gender.
It is therefore important for adjusters to obtain this information from all claimants.
What happens if a claimant (or claimant’s attorney) refuses to give out the SSN or HICN? This information is critical for the query. CMS has issued this Alert to help inform those unwilling to provide such information of why the information is necessary. CMS issued this Alert indicating that those claimants who refuse to provide the information should be required to sign a document with this Model Language in order for the insurer to be compliant with the reporting requirements. Otherwise, it is best for the adjusters to make every attempt to obtain the SSN or HICN information from all claimants. For claimants who have instituted litigation against an insured, the attorneys handling the insured’s defense should obtain this information in discovery.
Why run checks on all claimants if the reporting rules only apply to Medicare-eligible claimants? Because it is too difficult to determine whether the claimants are, in fact, Medicare eligible. Nowadays, it might be easy for medical institutions to find if the person is eligible for medicare by using software such as an MBI lookup tool (Medicare Beneficiary Identifier), that can help in all medicare transactions such as billing, claim submissions, etc.
Persons under age 65 can be eligible for Medicare if they have End Stage Renal Disease or certain disabilities. While you make assume that a 30-year-old claimant is simply too young to be eligible for Medicare, that claimant may be a Medicare beneficiary because he is on Social Security Disability or suffering from End Stage Renal Disease. Because age is not the only factor for Medicare eligibility, it is important to run the query for every claimant that doesn’t admit to Medicare eligibility to avoid inadvertently violating the reporting rules.