Briefing: Medical Positive Cases - PowerPoint PPT Presentation

briefing medical affirmative claims how should mac work date 21 march 2007 time 1610 1700 l.
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Briefing: Medical Positive Cases

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  1. Briefing: Medical Affirmative Claims – How should MAC work? Date: 21 March 2007 Time: 1610 - 1700

  2. Objectives • Identify Legal Authority requiring Medical Care Recovery / Medical Affirmative Claims (MAC) • Identify what is included in the MAC Program • Identify how to improve the identification and collection of MAC information • Identify the requirements of the MAC Billers in the MTF • Identify requirements of the NLSO Claims Office – JAG Code 15 • Identify reporting requirements • Identify the Charge Master Based Billing system will impact MAC

  3. Legal Authority • Federal Medical Care Recovery Act (42 U.S. Code, Chapter 32, Sections 2651 – 2653) • Collections From Third Party Payers (10 U.S. Code, Chapter 55, Section 1095 • Federal Claims Collections Act (31 U.S. Code, Chapter 37, Section 3711) • Worker’s Compensation Statutes - Federal and State

  4. What is included in the MAC Program? • Motor Vehicle Accidents - Automobile, Motorcycle, Boating, etc., caused by another party or the beneficiary injured • Personal Injuries – Slip & Falls, Dog Bites, etc. • Product Liability – Silicone Breast Implants, Phen Phen Diet Pills, etc. • Medical Malpractice – suit is against a civilian hospital, or private medical practice. Treatment/care to correct/repair was provided by the MTF • Worker’s Compensation – Treatment/care provided to beneficiaries for work related injuries. Does not include care/treatment provided to Federal employees or Active Duty Military Personnel who are injured on their DoD job

  5. Who Is Responsible? • Everyone in the MTF is responsible for the success of the MAC Program, but the UBO is responsible for overseeing the MAC Program at the MTF • UBO MAC staff must provide training to all of the departments/clinics/ancillary services in the MTF on how to identify “potential” MAC cases • The UBO must provide the department/clinics/ ancillary services with the MAC questionnaires to be completed by the patient

  6. Duties of the MAC Biller • Train and maintain a relationship with the front desk staff in the various clinics, ancillary services throughout the MTF, especially in the ER and Admission Office • Obtain completed MAC questionnaires and determine if there is a potential MAC case • Receive requests for Medical/Dental care costs from civilian attorney’s, insurance companies, and military legal offices (All requests should be coming via the NLSO) • Identify all inpatient care, outpatient care, and ancillary services provided to the patient since the Date of Accident/Injury/Illness that are related to the injury / illness • Obtain all medical records and other documentation supporting the care/services identified as related to the injury / illness

  7. Duties of the MAC Biller (con’t) • Generate the appropriate claim form(s) / invoice to be provided to the NLSO, Army JAG, or Air Force JAG responsible for adjudicating the government’s claim • Maintain a file (electronic or paper) of all claims/invoice submitted to the NLSO, Army JAG, or Air Force JAG, including all documentation submitted with the claim(s) / invoice • Maintain a claims tracking system, identifying all claims submitted, where they were submitted, original amount of the claims submitted, and the actual amount collected, and reason for any adjustment or denial • Submit reports to the BUMED Regional UBO Program Managers

  8. Reporting Requirements

  9. NLSOResponsibilities • Receive all incoming request for costs of Medical Care from Civilian attorneys and insurance companies • Obtain a signed agreement from civilian attorney’s that state they will represent the interests of the government. Placing the attorney/insurance company on notice that the government will have a claim if any medical/dental care was provided by the MTF related to the accident/injury • Forward requests and all additional documentation to the MAC Office • Forwards all claims/invoices to the appropriate attorney and or insurance company in a timely manner to comply with the statute of limitations pertaining to that claim/case • Collect all monies due to the government, depositing the collections to the correct Line of Accounting (LOA) for the MTF that submitted the claim/ invoice

  10. NLSO Responsibilities (Con’t) • Provide monthly reports to BUMED Regional UBO Program Manager, identifying claims received, amount billed, amount collected, claims closed, and reason for receipt of less than 100% of what was billed or total denial • Meet with the BUMED Regional UBO Program manager and Legal Officer to discuss compromised claims, claims closed without collections, and develop process improvements

  11. Summary • Be knowledgeable of the legal authority requiring Medical Care Recovery / Medical Affirmative Claims (MAC) • Know exactly what is included in the MAC Program so that you don’t waste time generating claims that will never be pursued • Work with the clinics and ancillary services in your MTF to identify and collect MAC information • Work with the NLSO Claims Office – don’t waste time creating and sending them claims they will never pursue • Only with the information we are collecting on the MAC Tracking spreadsheet can we prove what is being sent to NLSO for processing • Be patient, the Charge Master Based Billing system is coming and will include MAC. CMBB will have the same billing capabilities and reports as MSA and TPC