Why Timely Ongoing Responsibility for Medical (ORM) Termination is so Important in MMSEA Section 111 Reporting


If you work with workers’ compensation or no-fault/auto claims involving Medicare beneficiaries, you should be familiar with Ongoing Responsibility for Medical (ORM) as a requirement of MMSEA Section 111 Reporting.

According to the NGHP User Guide, the reference to “ongoing” is not related to “ongoing reporting” or repeated reporting of claims under Section 111. Rather, ORM refers to the Responsible Reporting Entity’s (RRE) responsibility to pay, on an ongoing basis, for the injured party’s (Medicare beneficiary’s) medicals associated with the claim. This often applies to no-fault, and workers’ compensation claims but may occur in some circumstances with liability insurance (including self-insurance).

The trigger for reporting ORM is the assumption of ORM by the RRE—when the RRE has decided to assume responsibility for ORM or is otherwise required to assume ORM— not when (or after) the first payment for medicals under ORM has been made. Medical payments do not actually have to be paid for ORM reporting to be required.

ORM can last indefinitely until the RRE is able to terminate legal responsibility to pay for ongoing medical treatment. As CMS guidance has been relatively clear and has set out four main categories in which ORM termination can occur, RREs should familiarize themselves with the CMS guidance on this issue.

As a background, the four (4) main categories in which an RRE can populate an ORM termination date are the following (See Section 6.3.2 of the NGHP User Guide):

1) Where there is no practical likelihood of associated future medical treatment, an RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required.

2) Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:

a. No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and

b. No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim;

c. Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and

d. The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000. * Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria above.

3) Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract.

4) Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.

The administrative closure of a file on the RRE’s part does not warrant an ORM termination under CMS' guidelines. Medicare uses Section 111 MMSEA data to coordinate Medicare benefits. Under the MSP, Medicare cannot pay if another plan has paid or is reasonably likely to pay. Medicare suspends benefits because the ORM data tells CMS that the RRE is responsible for current related treatment.

When the RRE reports to Medicare that ORM has terminated, CMS' expectation is that it is for one of the four reasons above. Any ORM termination date that does not coincide with Medicare's rules subject the RRE to potential exposures. Even more imminent is that proper ORM reporting and termination will likely be a point of focus when CMS finalizes its Proposed Rule on Civil Monetary Penalties (CMPs) for failure to properly comply with Section 111 requirements. Thus, RREs are advised to manage ORM termination dates with care.

By Heather Schwartz Sanderson

Courtesy of Sanderson Firm PLLC

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