Did you know that CMS provides nearly 100 different reports to Medicare Advantage and Part D plans? These reports cover membership, finance, PDE, encounters and more.
Let’s take a moment to focus on the MARx reports. CMS holds plans responsible for submitting timely and accurate information regarding beneficiaries’ enrollment, disenrollment, special membership status, and state and county code changes. To facilitate this, CMS is responsible for providing plans with reports verifying membership and payment information to ensure complete and accurate reconciliation. That sounds easy enough; plans must review and process all CMS-provided reports. However, many plans only use a portion of the CMS MARx reports. Accurate membership data is critical not only for compliance and revenue optimization, but also creates the best member experience. Inaccurate membership data can lead to members being denied access to benefits and services, which leads to complaints, appeals, and possible corrective action by CMS.
CMS also provides reports to plans for information verification, as detailed in the Plan Communication User Guide. Here are some examples on how these reports should be used:
Medicare Fee For Service Payment Reports
Some reports have very specialized data, with limited use in the overall reconciliation effort. A few reports which are important to prevent double-dipping (or duplicate payments), yet which are least used by plans, are “Miscellaneous and Other,” “Part B Claims Data File,” “HMO Bill Itemization Report,” “Monthly Summary of Bills Report,” and “Payment Record Report”. These files identify claims that were paid under Medicare Fee-for-Service for a date of service when the member is enrolled in the plan. These reports should be reviewed for claim recovery opportunities.
Agent Broker Compensation Data File
Some plans aren’t aware that they are required to use the CMS “Agent Broker Compensation Data File” to identify whether an enrollee is new or renewing. Many plans assume ‘new or renewing’ is defined by their enrollment in the plan, but CMS measures this based on whether it is a new enrollee to any Medicare managed care plan. An enrollee can be “new” to the plan but still classified as a “renewal” because of their prior enrollment history. CMS states that “Plans are responsible for using this information together with their internal payment and enrollment tracking systems to determine if an agent was used and the amount to pay the agent.”
Medicare Secondary Payer vs Coordination of Benefits Files
The “Medicare Secondary Payer” and “Coordination of Benefits” files have overlap between the data sets but have very distinct purposes and regulations that apply to each report. The “Medicare Secondary Payer (MSP) Information Data File” is to identify members where the capitation payment is reduced for reported Employer Group Health Plan other coverage information by 86-87%. The CMS Medicare Secondary Payer Manual governs the MSP rules, and because this is a special status indicator that impacts payments, it must be reviewed, validated, and updated monthly as part of the enrollment and payment reconciliation requirements. This file can be up to 50% outdated with invalid other coverage information and is a significant revenue optimization opportunity for plans. The “Coordination of Benefits (COB) – Other Health Insurance (OHI)” report communicates coverage that is primary and secondary to the plan. The plan requirements for managing this file are found in the Prescription Drug Benefit Manual Chapter 14 and apply to all plans that offer Part D. Both files must be worked on a monthly basis.
Rebellis recommends creating a master file directory that identifies the owner of each report, what systems or processes use the report, the intended purpose, the location and any data load or conversion requirements, and distribution details (e.g. email). This can also help maintain the organization’s overall institutional knowledge and more easily identify the responsible owner when changes are made to a CMS file.
To complete the final month-end reconciliation, plans should reconcile the “Daily Transaction Reply Report” with the “Monthly Membership Report,” “Plan Payment Report,” “Monthly Premium Withholding Report Data File,” “Low Income Subsidy,” and “Late Enrollment Penalty Data File”. The plan should ensure that the CEO or CFO that is submitting the attestation of enrollment and payment accuracy has comprehensive summary reporting confirming that full and complete reconciliation has occurred. Attesting to the accuracy of membership and payment reports without validation is non-compliant.
If you need assistance utilizing the CMS MARx reports for compliance and revenue optimization, contactus@rebellisgroup.com