WC Data Match

The Health Insurance Portability and Accountability Act includes a provision which establishes the Medicare Integrity Program (MIP). This provision gives CMS the authority to enter into contracts with entities to promote the integrity of the Medicare program. The MIP includes a range of Medicare program areas such as cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program.

Pursuant to the MIP authority, CMS awarded the Coordination of Benefits (COB) Contractor the responsibility for MSP activities. The COB Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. By law, when Medicare beneficiaries have certain private insurance, other insurers should pay first. The COB Contractor collects information on the proper order of payers, and ensures that Medicare makes primary payment only for those claims where it has primary responsibility. When mistaken Medicare primary payments are identified, recovery actions from other insurers are undertaken.

42 USC 1395y(b) establishes that Medicare is the secondary payer to workers' compensation (WC) and has a priority right of recovery over that of any other entity to the proceeds of any settlement of an individual's claim and a subrogation right. Beneficiaries are required to file for all workers' compensation benefits for which they can reasonably be expected to obtain compensation. The parties are required by statute and regulations to protect Medicare's interest when resolving WC cases, including both past and future medical payments. For more information regarding CMS WC policy regarding future medical payments, please see § 1395y(b) and § 1862(b) of the Social Security Act and 42 CFR Part 411, including regulations in Subpart C, which are specific to WC.  To avoid future overpayment negotiations and penalties, it is clearly in everyone's best interests, Medicare, the WC agencies, and the claimants - for all parties to work together.

WC Data Sharing Agreements

The voluntary data exchange program between the states and the Center's for Medicare & Medicaid Services (CMS) has now ended. On July 1, 2009, Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (the MMSEA) became effective for Workers' Compensation insurance coverage. As of that date, the reporting of Workers' Compensation information in support of Medicare Secondary Payer (MSP) determinations by CMS became mandatory. All existing voluntary data exchange arrangements involving Workers' Compensation programs are now null and void. Click on the “WC Data Match” section page and scroll down to the bottom of the page to “Downloads” to view an example of the cancellation letter provided to the states that were participating in the data exchange program.