Frequently Asked Questions on Ongoing Responsibility for Medical (ORM)

                               

In Franco Signor's oversight of numerous MMSEA Section 111 programs nationwide, we frequently answer many questions from clients surrounding Ongoing Responsibility for Medical (ORM). The confusion is understandable as ORM can be complicated. Let’s explore the various types of questions that we most often receive:  

What constitutes ORM?

CMS defines ORM as a Responsible Reporting Entity (RRE)’s responsibility to pay for medicals associated with the claim. CMS further provides that ORM does not mean the reporting of each payment for a medical service for the injured party, nor does it mean the ongoing reporting of ORM for the same claim each quarter. Instead, it is a report of the fact that ORM has been assumed for a particular claim for a particular period of time.

ORM is typically flagged in no-fault style policies, such as MedPay, Auto insurance, and workers’ compensation. Liability claims typically never have an obligation to report ORM as liability style policies do not directly pay for a beneficiary’s medical expenses during the pendency of a claim.

When does ORM need to be reported?

The trigger for an RRE to report ORM is not necessarily when the RRE has made the first medical payment, but rather when the RRE has made the determination to assume ORM or where the RRE is required to assume ORM.

In other words, if the beneficiary has filed a claim but if no medical payments have been made, whether ORM should be reported as “N” or “Y” would depend on whether the RRE has the intent or requirement to assume ORM. Assuming no medical payments have been made since the RRE believes the claim to be denied, ORM should be “N. “However, on the other hand, if no medical payments have been made but the RRE intends to or is required to pay for medicals should later medical bills present itself, the RRE should report ORM as “Y.”

When can ORM be terminated?

This is possibly the most complicated question of all that we receive relative to ORM. Essentially, there are three main categories in which an RRE can populate an ORM termination date: 1) The medical benefits to the claimant have exhausted under state law; 2) The treating doctor has provided a letter that future medical treatment related to the case has completed; or 3) The case has settled and the carrier has terminated its responsibility to fund future medical as part of that treatment.

It is extremely important to note that administrative closure of a claim does not equal ORM termination under CMS’ guidelines. For more information on ORM termination, please see our prior blog on this topic here.

What affect does reporting ORM to the Centers for Medicare & Medicaid Services (CMS) have upon coordination of benefits and recovery?

CMS tells us, and we know from experience that the Benefits Coordination & Recovery Center (BCRC) posts ORM records for Medicare claims processing use, so that claims for the same incident or injury are checked and not paid primary by Medicare if there is other insurance that should pay first. CMS’ key for claims processing actions related to these records is knowing a record has or had ORM – hence, the ORM Indicator is key to Section 111 processing.

Further, the ORM Indicator will also trigger Medicare’s recovery efforts. When ORM is indicated, the Commercial Repayment Center (CRC) will search Medicare records for claims paid by Medicare for medical services and supplies related to the beneficiary’s reported illness or injury. The claims search will include claims from the date of incident to the current date or the date ORM ended (ORM termination date).

It is important to make sure to terminate ORM where applicable. Often times, we will find that an RRE is shocked to be receiving conditional payment notices thinking that a claim is closed, but when looking into their Section 111 data, it is realized that ORM was not terminated timely.

ORM and Section 111 requirements can be puzzling. CMS may fine an RRE for up to $1000 per day/per claim for noncompliance. Contact me for any questions on ORM or MMSEA Section 111 requirements.

 

About the Author

Heather Schwartz, Esq., MSCC, CHPE, CLMP, CMSP

Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP

Heather is Chief Legal Officer for Franco Signor LLC, the nation's compliance authority for Medicare Secondary Payer (MSP) matters. She has lectured on MSP compliance to the workers' compensation and liability insurance communities at conferences, associations, and individual offices nationwide. She is a regularly published author on court decisions and legislative reforms involving Medicare Set-Asides, conditional payments, and Mandatory Insurer Reporting issues. Understanding that compliance with the Medicare Secondary Payer Act can be at times complex and frustrating for those that handle claims with Medicare beneficiaries, Heather's goal is to speak and write with the primary goal being simple and understandable solutions to compliance. 

Heather can be reached at Heather.Sanderson@francosignor.com
Franco Signor's Blog can be found at: http://www.francosignor.com/msp-blog/


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