March 20, 2018

Eileen Auen: Achieving Compliance with Mandatory Insurer Reporting

Eileen Auen, Chairman and CEO, PMSI
Eileen Auen, Chairman and CEO, PMSI

The Mandatory Insurer Reporting (MIR) process is complex and affects multiple data sources and processes within the claims management process. The risk and cost of achieving compliance with MIR requirements has elevated this issue to the very top decision making levels of payer organizations. With penalties of $1,000 per day per case, payers have been very focused on understanding responsibilities and resolving issues impeding compliance.

Mandated by the Medicare, Medicaid and SCHIP Extension Act (MMSEA), MIR is the accounting of open claims for Medicare beneficiaries via electronic submission to the Centers for Medicare & Medicaid Services (CMS). MIR is another initiative in the ongoing effort to protect the Medicare Trust Fund through the enforcement of the Medicare Secondary Payer (MSP) Act that deems Medicare the secondary payer whenever a primary payer exists. Reporting for workers’ compensation payers commenced on January 1, 2011 and liability reporting is scheduled to begin on January 1, 2012, yet many of those primary payers—defined as Responsible Reporting Entities (RREs)—are still struggling with challenges to meet MIR requirements.

First of all, who is an RRE? As simple as this sounds, there continues to be confusion as to who is defined as the RRE and bears the ultimate financial responsibility to ensure claims are reported. CMS defines the RRE as the insurer or self-insured plan—not third party administrators or claimant/plaintiff counsel. Most RREs choose to contract with a third-party provider to act as their Reporting Agent, a permissible arrangement that does not violate any MIR requirements. However, this does not relieve the RRE’s responsibility for reporting. RREs retain all responsibility including financial responsibility for any fines associated with non-compliance. As a result, payers need to have their Reporting Agent clearly and accurately deliver the appropriate information to ensure compliance with MMSEA Section 111 requirements.

The reporting requirements for MIR include 140 CMS-specific data fields that must be submitted electronically. The data elements required for reporting and the electronic submission process are incompatible with many legacy systems. Monitoring and complying with changing requirements can be a daunting task and require cost prohibitive IT investments. It is this broad scope and high-level of investment needed to meet these requirements that prompt many RREs to partner with a designated Reporting Agent.

With an extensive amount of required data elements and complex requirements, it is easy to see how problems can arise. Managers need to ensure that Reporting Agents are accurate and timely with the submission of the RRE’s reports. PMSI has queried and/or reported over 1 million claims through our MedicareConnectSM solution and can offer these insights into the process:

  • Not all claims are necessary to report. We found an average of 25.6% of the positive beneficiaries we received did not require reporting, based on CMS published thresholds By processing these claims through MedicareConnect’s built-in business rules based on the CMS User Guide, we found only 74.4% were reportable. A reporting system that provides automated checking of claims against reporting requirements will minimize the time spent gathering and validating the information required for reporting.
  • Data must be error-free, before submission. Approximately 50% of reportable claims we received contained invalid values in required fields, which had to be corrected in order to be accepted by CMS. Submitting data with an error rate higher than 20% will result in temporary suspension of report review and response by CMS. PMSI has been able to achieve a 99.7% acceptance rate on submissions to CMS, by automatically scrubbing the data up front. A reporting system with data aggregation capabilities, automated data validation process and automated alerts for reporting will reduce risk and limit additional work associated with errors.
  • Technology is a vital function of the MIR process. Many legacy systems are incompatible with electronic reporting and require a significant investment in IT, resources and time. Over 50% of the claims in error are due to invalid ICD-9 values. MedicareConnect uses keyword searches allowing users to correctly identify ICD-9 and E-codes that are accepted by CMS. A reporting system with up-to-date, industry-specific information, flexible data transmission options and secure and established system platforms is necessary to achieve efficient MIR reporting.

MIR reporting is complex. A partner with in-depth regulatory knowledge and the technical capabilities to include data aggregation is necessary to achieving compliance. A scalable system with validation to streamline the reporting process, identify issues, and manage RRE work is necessary to enable claims managers to effectively manage the efforts needed to ensure compliance. Now that reporting has been underway for 9 months, we expect Medicare to begin to more closely scrutinize the data that has and is being submitted. At a time when compliance is expected, it is important to pick your partners carefully.

About Eileen Auen
Eileen Auen is the chairman and CEO of PMSI, a leader in developing solutions to control the growth of medical costs in workers’ compensation. In 2010, Auen was named one of Business Insurance’s Women to Watch. In 2011, she was selected as Business Woman of the Year, in the Business Services category, from the Tampa Bay Business Journal. Eileen’s previous positions include serving as CEO of APS Healthcare as well as executive positions at Aetna, CIGNA and HealthNet.

About PMSI
PMSIFounded in 1976, PMSI is a leader in developing solutions to control the growth of medical costs in workers’ compensation. As one of the nation’s largest and most experienced companies focused solely on workers’ compensation, we deliver proven solutions for cost containment across the claims lifecycle. PMSI’s solutions for Pharmacy, Medical Services and Equipment, and Settlement Solutions deliver quantifiable results and improve the quality of care for injured workers. We provide our customers with the innovation, focus, expertise, analytics and technology needed to successfully deliver workers’ compensation benefits.

For more information on PMSI’s proven solutions for cost containment, visit:

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