What is Ongoing Responsibility for Medicals (ORM)?
Ongoing Responsibility for Medicals (ORM) refers to a Responsible Reporting Entity’s (RRE) obligation to cover medical payments for a Medicare beneficiary. This responsibility arises when an RRE assumes responsibility for a beneficiary’s medicals, either voluntarily or as required under an insurance contract.
ORM signifies a continuous duty to manage medical claims related to an injury or illness, ensuring timely payment and accurate ORM reporting to Centers for Medicare and Medicaid Services (CMS).
Medicare’s Role in ORM
The Centers for Medicare and Medicaid Services (CMS) mandates ORM reporting under Section 111 of the MMSEA (Medicare, Medicaid, and SCHIP Extension Act). The CMS User Guide provides the latest updates on ORM compliance, requiring Responsible Reporting Entities (RREs) to:
- Report ORM within 135 days of assuming responsibility.
- Submit the ORM Indicator, ORM Termination Date, and Diagnoses Codes.
- Ensure proper documentation of medical claims and service-related treatments.
Failure to comply with ORM reporting regulations can result in significant penalties.
Managing Ongoing Responsibility for Medicals
RREs must actively manage ORM by:
- Tracking Medical Claims – Monitoring all claims paid related to the injury.
- Reporting ORM Updates – Keeping CMS informed on any changes, including ORM termination.
- Determining ORM Termination – Identifying the practical likelihood of future medical treatment through physician statements.
ORM ends when no further medical implantation, prosthetic device, or additional medical items are expected for the injury.
Medicare Secondary Payer (MSP) Compliance and ORM
Under the Medicare Secondary Payer (MSP) Act, ORM reporting ensures Medicare is not incorrectly billed for medical payments that should be covered by another payer.
- ORM compliance is crucial for avoiding fines.
- Non-Group Health Plans (NGHPs), such as workers’ compensation plans and no-fault insurance, must adhere to state law when reporting ORM.
- ORM reporting involves capturing diagnoses codes related to the injury to determine the termination date.
ORM Termination and Reporting Requirements
An RRE must terminate ORM when:
- The injury no longer requires future medical treatment.
- A physician statement confirms the practical likelihood of further treatment is low.
- The responsible insurer has fulfilled its financial obligation per the insurance contract.
The ORM Termination Date must be reported within 135 days of the effective date of termination.
ORM Reporting Process and Data Submission
The ORM reporting process involves:
- Submitting an ORM Indicator to CMS.
- Providing the correct diagnoses codes related to the injury.
- Reporting ORM updates through the CMS User Guide.
- Confirming ORM termination details, including the date and reason.
Failure to report ORM terminations correctly can lead to claims paid related errors.
CMS Updates and ORM Rule Changes
CMS regularly updates ORM policies, requiring RREs to stay informed on new compliance standards.
- Recent changes allow ORM termination based on a beneficiary’s treating physician certification.
- ORM compliance involves continuous monitoring of medical services and alleged ingestion claims.
- The CMS User Guide is updated frequently to provide the latest ORM reporting standards.
Frequently Asked Questions About ORM
What does ORM mean for Medicare?
ORM ensures that a Medicare beneficiary’s medical costs are covered by an insurance contract before Medicare pays.
What does ORM mean in medical terms?
ORM refers to the Ongoing Responsibility for Medicals, where an insurer or employer continues to cover medical expenses related to an injury or illness.
What does ORM stand for?
ORM stands for Ongoing Responsibility for Medicals, a mandatory reporting requirement under Medicare Secondary Payer (MSP) regulations.
What does ORM Termination Date mean?
The ORM Termination Date is the date when an RRE determines that the practical likelihood of further treatment no longer exists and submits this information to CMS.
Proper ORM management requires a thorough assessment of any associated future medical treatment that may arise from an injury or illness. RREs must evaluate the likelihood of ongoing care, rehabilitation, or the need for medical implantation devices to determine if ORM should continue. This process often involves consulting with the beneficiary’s treating physician to verify whether any further treatment is medically necessary. Failing to consider associated future medical treatment can lead to compliance issues, as Medicare must not be billed for expenses that another entity is responsible for under an insurance contract.
When an RRE handles such claim, it’s essential to document all relevant medical information to support ORM decisions. This includes maintaining records of medical claims related to the injury, physician assessments, and any treatment plans outlining potential associated future medical treatment. If there’s no longer a practical likelihood of needing additional care, the RRE can proceed with ORM termination. However, in cases where such claim remains active, continuous monitoring is required to ensure proper reporting and compliance with CMS guidelines.
Conclusion
Understanding Medicare ORM is essential for Responsible Reporting Entities (RREs) to ensure compliance with Medicare Secondary Payer (MSP) regulations.
- Proper ORM reporting prevents Medicare from being billed for costs that another payer should cover.
- Accurate tracking of medical claims, medical items, and services is crucial for compliance.
- RREs must monitor CMS User Guide updates to stay informed about changes in ORM rules.
Failure to comply with ORM termination and reporting ORM can result in penalties, making ORM management a priority for insurers and employers.
