PAID Act Becomes Law

Last week we provided an update on the progress of the PAID Act, which was passed in the House on December 8th.  It only took a few more days for the act to become law.  On Friday, the PAID Act was inserted into a HR 8900 which extended government funding through December 18, 2020 but also included a number of provisions associated with Medicare.  The PAID Act is now law, as Section 1301 of the “Further Continuing Appropriations Act, 2021, and Other Extensions Act.”

What is the PAID Act?

The PAID Act requires Medicare to share Medicare Advantage Plan information through the Section 111 query process.  Under the current program, Medicare will notify insurers that an individual has been identified as eligible for Medicare benefits.  The query process does not indicate that the individual is actually receiving benefits, nor where those benefits originate.  The query process merely identifies that the person is or was eligible to receive Medicare benefits at some point in the past, present, or future. 

The PAID requires Medicare to provide substantial detail as part of this process, including the name and address of any Medicare Advantage or Part D plan that the individual has enrolled in within the last three years.  The PAID Act also requires Medicare to confirm that the individual was actually entitled to Medicare benefits within the last three years – unlike the current query process which can result in “positive” queries even if benefits have been long terminated.  Medicare will have one year to implement these changes.

A coalition of insurance industry organizations, led by the MARC Coalition, pushed for the PAID Act’s passage in response to a litany of class-action lawsuits seeking to enforce Medicare Secondary Payer provisions on behalf of Medicare Advantage Plans.  Because claims organizations have no visibility into a Medicare beneficiary’s enrollment information, primary payers are at risk of post-settlement lawsuits even when no party was aware that a claimant was enrolled in Medicare Advantage at the time of the settlement. The PAID Act creates the mechanism to ensure transparency and close this knowledge gap.

What is next?

The PAID Act will bring technical changes to the query process.  Over the course of the next several months, we expect Medicare to release updated guidance regarding the content of those changes and the timeline for implementation. The query process currently provides only very limited information, so companies should prepare for technical development if they choose to ingest the additional enrollment details.  The query process is entirely optional, so it is conceivable that some companies will forego the option to accept this additional information.

ExamWorks Compliance Solutions will update its systems to ensure a seamless implementation for all clients.  Not only will we accept the additional details, but we will have a number of data, technical, and claims oriented solutions available for clients.  The Section 111 Reporting and Compliance Teams at ECS will closely monitor the changes and provide frequent updates on their impact.  Should you have any questions, please contact VP of MSP Compliance Marty Cassavoy at martin.cassavoy@examworkscompliance.com or Senior VP of Information Technology Scott Huber at scott.huber@examworkcompliance.com

Marty Cassavoy

Marty Cassavoy

Marty Cassavoy is the Vice President of MSP Compliance at ExamWorks Compliance Solutions. Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer compliance and across all insurance types. An attorney licensed to practice law in Massachusetts, Marty works out of ExamWorks’ Woburn, Massachusetts office and can be reached at 781-517-8085 or martin.cassavoy@ExamWorksCompliance.com

Scott Huber

Scott Huber

Scott Huber is the Senior Vice President of Technology at ExamWorks Compliance Solutions. Scott oversees all internal and external technology services for ECS, including the award-winning MIR Service Section 111 Reporting platform. A native Floridian, Scott is a graduate of the University of Florida and works out of ECS headquarters in Lawrenceville, Georgia. Scott can be reached at 678-256-5135 or scott.huber@ExamWorksCompliance.com

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