CMS has a unique reporting requirement for those claims in which the reporting entity has an “ongoing responsibility” to pay medical claims, either because the entity has accepted that obligation voluntarily or because state workers compensation or no-fault laws require that result for a fixed period or for the lifetime of the claimant. Although initial ORM reporting is understandable, the Agency has made it unnecessarily difficult to terminate such reports. More specifically, as set out in Chapter III, Section 6.3 of the NGHP User Manual, ORM reporting can only terminate when a state statute of limitations has expired on future claims or when a beneficiary’s treating physician issues a letter stating no further treatment is necessary. These letters are near impossible to secure. In addition, several states have no limitations period for claims repayment. As a result, many ORM claims remain open for years, and may be open for decades.
The implications of not being able to timely terminate ORM claims is significant for the MSP stakeholder community. Medicare often incorrectly denies Medicare Beneficiaries coverage for unrelated medical expenses when similar “ICD” codes appear in an ORM claim.
Medicare has denied pain medications to dying hospice patients due to an ORM workers’ compensation claim for a cut on the hand years earlier which also required pain medications.
Similarly, Medicare has denied coverage for breast cancer treatment because a beneficiary had previously had a small slip and fall bruising her right-side chest.
In addition, insurers and other companies encounter administrative burdens and cost in reporting ORM claims repeatedly, for years and sometimes decades, facing “reporting” penalties for not timely terminating ORM claims that the government’s instructions will not permit to be terminated. And even CMS systems will soon be overwhelmed, as millions of open ORM claims with no possibility of being closed will back up in the CMS systems.
MARC has long been advocating for ORM termination reform. MARC’s proposals include allowing “no further treatment” letters from individuals other than the beneficiary’s treating physician, permitting termination if no medicals claims have been filed on a matter in three years, and adoption of a five-year statute termination date in those states that do not have a statute of limitations. MARC continues to work with CMS on this important issue, which is significant to Medicare beneficiaries and entities that work to settle these types of claims.