Things That Make You Love and Hate Measuring and Monitoring

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Data-Driven concepts are everywhere. Data Driven Decision -Making is common vernacular today. Having clearer insights into business information, processes and outcomes is becoming an Operations requirement across all industries. The last bastion of innovation is happening now in the Insurance industry. Technology innovation, known as InsurTech, is disrupting the industry and the old familiar, processes of managing risk, underwriting, customer support and claim management. The result of accelerating data analytics insights is greater regulatory and consumer demand for transparency.

On September 10, 2021, House democrats voted to include Federal monitoring of State Workers Compensation in the 2022 Budget Reconciliation, giving authority to the US Department of Labor Office of Workers Compensation Programs (OWCP) to “monitor” State Workers Compensation programs.

On October 19, ninety-one stakeholders submitted a letter to the House and Senate in opposition of Federal monitoring of Workers Compensation stating the imposition of “monitoring” by the Federal government is not necessary and not consistent with the budget reconciliation rules. Within days, highlighted some of the key issues Workers Compensation lobbyists will be focused on. One of those issues was the potential for Federalization of Workers Compensation.

This is not first time Federalization has been a concern, in fact it has been a recurring issue for reasons that State benefits, fee schedules, regulation and the variability in the administration of Workers Compensation varies from State to State creating a perceived inequity in the administration of Workers Compensation among injured workers. It is assumed in Congress that Federalization would provide more consistency in benefits and cost and greater transparency into the Workers Compensation system.

In October, 2021, the National Academy of Social Insurance released it’s 24th Annual Workers Compensation report discussing benefits, costs and coverage, citing the difficulty of measuring the impact of legislative and regulatory changes due to a state-based system.

This made me think deeply, for several weeks. I spoke with our company advisors, Dick Palczynski and Dr. David Dietz and others in the industry. I explored the inconsistencies in Commercial health insurance and government-based health plans, comparatively. Traditional Medicare is delivered under established coverage guidelines, pricing, and rules for medical necessity. Under Medicare Secondary Payer, CMS ignores State rules and guidelines in the review of MSA Submissions. However, Medicaid administration of eligibility, benefits, costs, and coverage differs according to state. Each state can determine what is best for its constituents through the legislative process and state budgets, just like Workers Compensation.

While we LOVE the ability to measure and monitor services rendered to us by our vendor partners and stakeholders, we often HATE being measured or monitored by an external auditor, regulator or entity which places us in the vulnerable and uncomfortable position of staring at insights which may be less flattering to our business. This leads to the conclusion that the best defense against over-reach and Federal oversight is the use of tech-enabled platforms to effectively measure and monitor ourselves to demonstrate continuous process improvement and improved outcomes. For example, If I am using an enterprise risk management (ERM) platform for Medicare Secondary Payer, with visibility into all my claims, I cannot be accused by the Federal government of deliberately “shifting the burden” of claims’ liability to Medicare. But if I am not using data analytics to monitor my company and I cannot demonstrate a measurable approach to compliance, then the argument for Federal oversight gains more credibility.

For these reasons, Care Bridge International has been passionate about data analytic insights for claims since 2015. This year, the company released its API for automating medical reserve setting for claims, including the identification of Medicare exposure and a risk enterprise platform for Medicare Secondary Payer (MSP) compliance. With Care Bridge International’s technology, you can automate claim processes and make data driven decisions to manage risk and improve claim outcomes. Having visibility leverages against Federalization, to simply state oversight is “unnecessary” is a weak position at best.

As we close the year in 2021 and look back at our own accomplishments as an organization, our most significant milestones were made through thoughtful and deliberate measuring and monitoring of our goals and objectives. Moving into 2022, claims automation that will enable claim and risk managers to focus more on outcomes and make you LOVE how easy it is to measure and monitor claims, is our promise to you.

In Other News:

CMS Updates:

Effective December 11, 2021, the PAID Act requires CMS to provide Responsible Reporting Entities (RRE), in the Section 111 “query” response file, the name, address and plan number of each Medicare Advantage (Part C) and Medicare Prescription Drug (Part D) Plan that a Medicare beneficiary was enrolled in for the three years prior to the date of the query. For dates older than three years, Care Bridge International is uniquely able to retrieve eligibility for its clients in minutes. Our Risk Enterprise platform offers complete visibility into compliance for your peace of mind with generous cost savings.

On December 20, 2021 CMS released an updated MMSEA Section 111 NGHP User Guide version 6.6 and 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide version 5.8 Refer to Chapter 1 for a summary of updates

Out and About:

In case you missed Care Bridge International at the 75th Annual Workers Compensation Educational Conference in Orlando, December 15-18, 2021, view our Video Interview here!

Interested in Learning More about how Care Bridge International’s API?

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