What are conditional payments?  How and when should payers respond to Conditional Payment Letters, Notices and Demands? What happens if you don’t? Our Chief Compliance Officer Dan Anders and Director of MSP Compliance Services Ada Lopez covered these topics and much more in our February 7 webinar.  Here’s a quick recap.

How does Medicare know who the primary payer is … or that a case has settled?

The Medicare Secondary Payer Act was written to protect the Medicare Trust Fund. And the Centers for Medicare and Medicaid Services developed Coordination of Benefits (COB) rules and processes to keep Medicare from paying for treatment that is covered by a primary payer (workers’ compensation, liability, no-fault). If Medicare has made a payment for which a primary payer exists, then such a payment is considered conditional, meaning it is conditioned upon reimbursement to the Medicare Trust Fund.

Most commonly, CMS learns that a primary payer for a Medicare beneficiary’s claim exists through these Section 111 reporting triggers:

• Acceptance of Ongoing Responsibility for Medical (ORM), usually in a WC or no-fault claim
• Total Payment Obligation to Claimant (TPOC), typically a settlement

Timeliness and accuracy are keys to protecting the payers who are the Responsible Reporting Entities (RREs)

• ORM and TPOC should be reported via Section 111 every quarter.
• As of Oct. 11, 2024, RREs will be subject to penalties if ORM or TPOC are reported more than 365 days late. (Link to Penalty blog)
• Report valid ICD-10 codes:
  • For ORM, report only diagnosis codes that are accepted on the claim.
  • For TPOC, only report diagnosis codes that are released as part of the settlement.
  • Be careful to report only codes that apply to the claim. (Medical bills and records often contain non-claim-related ICD-10 codes.)

Conditional payment recovery

The webinar took a deep dive into the processes and communications the Benefits Coordination & Recovery Center (BCRC) and Commercial Repayment Center (CRC) deploy to obtain reimbursements. Dan and Ada also discussed ways to dispute conditional payment notices and demands.  It’s worth requesting a recording of the session from Dan (daniel.anders@towermsa.com) just to get this information.

Some best practices for conditional payments

• Make sure claims are accurately and timely reported for ORM and TPOC.
• Update ICD-10 codes when additional body parts are accepted or denied or they need correction.
• Terminate ORM when appropriate, e.g., settlement.
• Identify your Medicare-eligible claimants.
• Immediately review and act on conditional payment correspondence and meet the deadlines!
• Make sure settlement terms specify who is responsible for conditional payments post-settlement.
• When a Demand is received, either pay or appeal. Pay attention to Conditional Payment Letters (CPLs) and Conditional Payment Notices (CPNs) and take action on them, but do not pay before the Demand.
• Be sure to respond to the Demand on time. Otherwise, the debt will eventually be transferred to the U.S. Treasury.
• Follow-up with the CRC or BCRC to ensure payment was received and applied to the debt and that no debt remains.

If you don’t work with conditional payments on a daily basis, consider partnering with Tower for conditional payment identification, resolutions and appeals. And, if you have any questions about conditional payments, even on specific claims, or any other MSP compliance issues, Dan Anders is happy to answer them.  Email daniel.anders@towermsa.com.

Also, let us know what areas of MSP compliance you would like us to cover in future Premier Webinars. We want to help you.

The Centers for Medicare and Medicaid Services has announced that Total Payment Obligation to Claimant (TPOC) Section 111 reporting must include Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) effective April 4, 2025.  This means CMS will require workers’ compensation payers to report MSA amounts, even if $0, concurrently with settlement amounts, when the TPOC date is April 4, 2025 and later. See CMS’s February 23 Technical Alert for details.

CMS previously explained this significant expansion in a November 13, 2023 webinar (See CMS to Require Section 111 Reporting of WCMSA Amounts).

In the February alert, CMS reiterates that this new reporting requirement aims to improve coordination of benefits for Medicare beneficiaries.  Specifically, if a WCMSA is reported, then the WCMSA will be considered primary for payment before Medicare.

Notably, the WCMSA reporting requirement applies to both CMS-approved and non-approved MSAs.  The rule will be prospective only, meaning it applies to TPOC dates of April 4, 2025 and later.

To collect this data, CMS is adding new fields to the Section 111 Claim Input File. This information must be reported if the reported insurance type is workers’ compensation and the TPOC amount is greater than $0. Here is a look at the new fields:

• MSA Amount: This will be either $0 or an amount greater than $0.  If an annuity is used, then the “total payout” is reported.
• MSA Period: If the MSA amount is greater than $0, you need to enter the number of years the MSA is expected to cover the beneficiary.
• Lump Sum or Structured/Annuity Payout Indicator: If the MSA amount is greater than $0, you will enter “L” for a lump-sum MSA or “S” for a structured/annuity MSA.
• Initial Deposit Amount: If an annuity, then the MSA seed amount is reported.
• Case Control Number (CCN): If an MSA is submitted to CMS for review or is otherwise submitted to CMS post-settlement, it will be assigned a CCN.  The CCN is entered in this field, although this is optional.
• Professional Administrator EIN: If the MSA includes a professional administrator, enter the Employer Identification Number of the professional administrator here.  If a professional administrator EIN is not provided, the “case administrator” defaults to the beneficiary.  If the EIN submitted does not match a registered administrator account in the Workers Compensation Medicare Set-Aside Portal (WCMSAP), then “case administrator” will also default to the beneficiary.

CMS also provided a table of error codes if errors are identified in the above-reported information.

Testing of the new fields will be made available to Responsible Reporting Entities (RREs) beginning on October 7, 2024.

Key Takeaways

The data CMS requires to be reported is not commonly captured in payer and TPA claims systems.  Consequently, claims systems must be updated with the new fields and claims professionals will need to be trained on when, how, and what to enter into these fields.

Tower will work with our Section 111 reporting clients to provide further technical information on reporting these fields, including testing. We can also assist with capturing this data for reporting purposes.

Questions remain over what CMS will do with this data once it has it.  What if the Section 111 reporting data contradicts the CMS-approved MSA data?  If a non-CMS approved MSA exhausts prematurely (meaning the funds were insufficient to cover the number of years the MSA was to cover), will CMS step in and pay for injury-related medical care, or will they claim that it was underfunded?  If they claim that it was underfunded, does the individual have a right to challenge such a determination and how does that process work?

CMS states that this technical alert, with additional information, will be incorporated into an April 2024 version of the MMSEA Section 111 Mandatory Reporting User Guide.  We will provide further updates with the release of that document.

Please get in touch with Chief Compliance Officer Dan Anders at (888) 331-4941 or daniel.anders@towermsa.com with any questions.

The Centers for Medicare and Medicaid Services (CMS) issued a series of updates over the past month, which include an updated NGHP Section 111 User Guide, the latest Top 10 Section 111 Reporting errors, and its 2024 conditional payment recovery threshold.  We have summarized these for you below.

Updated NGHP Section 111 User Guide

CMS released NGHP User Guide Version 7.4, which incorporates the Section 111 civil monetary penalties rule into Section 5.1 of Chapter III: Policy Guidance of the guide. See our most recent update on Section 111 penalties in Recap of CMS Section Penalties Webinar.  CMS includes the following in the guide:

The occurrences to be audited will include both Section 111 submissions and records from sources outside of the Section 111 reporting process, to ensure that CMS does not miss those situations where an RRE has entirely failed to report the occurrence. RREs will only be informed when there is a potential instance of non-compliance.

In short, CMS will be auditing untimely reporting through Section 111 and reviewing reports outside of Section 111 to determine if there was a failure to report at all.

Top 10 List of Section 111 Reporting Errors

CMS released a chart of the Top 10 Section 111 Non-Group Health Plan Reporting Error Codes from 7/1/2023 to 12/15/2023.  The top three reporting errors were:

• TN – 99: No matching, valid TIN Reference File Detail Record was found for the TIN/Office Code combination on the Claim Input File Detail Record.
• CI05 – Invalid Diagnosis Code 1.
• SP49 – No previously accepted record can be matched to the submitted delete. Delete failed.

These issues are what CMS calls “hard errors,” meaning the record will be rejected.  Remember that if a record is rejected and not timely corrected, it could be subject to Section 111 civil monetary penalties for untimely reporting.

$750 Threshold Kept for Reporting and Conditional Payment Recovery

In a February 14, 2024 alert, CMS announced that the 2024 conditional payment recovery threshold for liability, no-fault and workers’ compensation settlements will remain at $750. Accordingly, Total Payment Obligations to the Claimant (TPOCs) in the amount of $750 or less do not need to be reported to CMS through the Section 111 Mandatory Reporting process. Nor will CMS attempt to recover conditional payments for TPOCs of $750 or less (The threshold does not apply to liability settlements for alleged ingestion, implantation or exposure cases.)

By way of background, pursuant to the SMART Act of 2012, CMS must determine a threshold amount each year to ensure the collection cost stays within the amount recovered through such efforts.

Please get in touch with Tower’s Chief Compliance Officer, Dan Anders, with any questions at (888) 331-4941 or daniel.anders@towermsa.com

Tune-up your conditional payment resolution processes with Tower’s Feb. 7 webinar!

Medicare conditional payment resolution should be a standard practice when settling workers’ compensation or liability claims that involve an injured worker or claimant who is a Medicare beneficiary.  While most settling parties recognize this obligation, many have questions about Medicare Secondary Payer (MSP) Medicare conditional payment requirements, conditional payment policies, the practices of CMS recovery contractors, and the role of the Treasury Department in debt recovery.

For the answers, join Tower for a complimentary webinar on Wednesday, February 7, at 2:00 PM ET. Dan Anders, Tower’s Chief Compliance Officer, and Ada Lopez, Director of Medicare Secondary Payer Compliance Services will tell you when and how to:

• Communicate with the Commercial Repayment Center (CRC) instead of the Benefits Coordination and Recovery Center (BCRC).
• Investigate conditional payments.
• Respond to Medicare conditional payment recovery correspondence.
• Dispute and appeal conditional payment demands- What works, what doesn’t work, and what sometimes works.
• Resolve Treasury Department debt recovery actions.
• Work with Tower to investigate, dispute and resolve conditional payments.

A Q&A session will follow the presentation and you can submit questions now.

Please click the link below and register today!

Note there is no CEU credit offered for this webinar.

Register Here

As we start the new year, here’s a look at the top five Medicare Secondary Payer (MSP) compliance stories of 2023 and what to watch for in 2024.

 A Look Back

Centers for Medicare and Medicaid Section 111 Penalties Rule Released

The long-awaited Section 111 penalties rule was published in October. Surprisingly, the final rule was more narrowly focused than the proposed version. Now, only untimely reporting (defined as one year later than it should have been reported) of Ongoing Responsibility for Medicals (ORM) and Total Payment of Claim (TPOC) is at risk for potential penalties. Not only that, not all claims that run afoul of the rule will be penalized. CMS will incorporate a randomized selection process to identify records for audit. Finally, CMS’s rule only applies prospectively, that is, with reportable data on October 11, 2024, and later.

See CMS Section 111 Penalties Rule Focuses on Untimely Reporting and CMS Releases FAQs on Section 111 Penalties for more details.

CMS to Require Section 111 Reporting of WCMSA Amounts

In a November 16, 2023 webinar, CMS announced plans to require the report of a Workers’ Compensation Medicare Set-Aside (WCMSA) amount concurrently with the report of TPOC in Section 111 Mandatory Insurer Reporting.  While CMS can presently coordinate post-settlement Medicare benefits when they receive settlement documents with an MSA amount, except for CMS-approved MSAs, this is not required.

CMS wants to close this information gap with a requirement to disclose an MSA amount included in a workers’ compensation settlement whether CMS approved the MSA or not. In the webinar, CMS indicated it would like to have the new reporting fields in place by January 2025.  This represents a technical and training challenge for Responsible Reporting Entities (RREs), who will now have to capture and report this data along with the currently required information.

More information can be found in our article, CMS to Require Section 111 Reporting of WCMSA Amounts.

Amended Reviews Open to All MSAs

Tower had urged CMS for some time to drop the past 60-month time requirement for an Amended Review and open it up to any prior WCMSA determination. We were pleased when CMS ended the 60-month requirement in May. It now allows a one-time Amended Review when a case meets this criteria:

• CMS has issued a conditional approval/approved amount at least 12 months prior.
• The case has not yet been settled as of the date of the request for re-review.
• Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

Further information can be found in CMS Significantly Expands Amended Review MSA Availability and MSA Amended Reviews – Key to Settlements of Old Dog Legacy Claims

Option for Unsolicited Response File on ORM Record Changes

Starting in July 2023, RREs had the option to receive a monthly NGHP Unsolicited Response File through the Section 111 secure website. The Unsolicited Response File provides the RRE with changes made to ORM records by the Benefits Coordination and Recovery Center (BCRC), which were not requested by the RRE, but rather are typically in response to communication with the claimant. The file allows the RRE to update or correct its reporting dataor report to the BCRC that the action taken is inconsistent with the RRE’s legal obligations in relation to ORM.

See Section 7.5 of the NGHP Section 111 User Guide, Chapter IV, Technical Information, for further information on the NGHP Unsolicited Response File.

Medicare Conditional Payment Appeals Guide

While it did not break any new ground on bases to appeal Medicare conditional payments, the April release of the NGHP Applicable Plan Appeals Reference Guide represents an important move toward CMS transparency around demand letter appeals. The guide clarifies both the policy and process for RREs or their representatives in submitting such appeals. Notably, Tower referenced the guide in successfully appealing a Medicare conditional payment demand before a CMS Administrative Law Judge.

A copy of the guide can be found here.

What to Watch for in 2024

Section 111 Penalties Implementation:  As the data to be considered for Section 111 penalties is October 11, 2024 and later, there is no possibility of a penalty being issued in 2024 (as the data must be reported one year late). When it released the rules, CMS stated that it would have further policy announcements and webinars. This includes a January 18, 1:00 pm ET, informational webinar. Details on the webinar can be found here.

Section 111 Reporting of WCMSA Amounts: CMS has tentatively set the start date for reporting WCMSAs as January 2025. The planned timeframe is for an updated file layout and error codes to be released in early 2024, with testing in the fall of 2024. CMS is expected to issue written guidance along with webinars on the topic.

New MSPRP Portal Features:  CMS has indicated it will continue introducing new Medicare Secondary Recovery Portal features. We will be on the lookout for these throughout 2024.

Medicare Beneficiary Appeals Guide:  In 2023, CMS released an appeals guide for NGHP plans to appeal Medicare demands from the Commercial Repayment Center. We expect CMS will also release a similar document for Medicare beneficiaries to appeal demands from the BCRC.

Finally, there will surely be other CMS announcements during the year. As always, we will provide you with summaries and key takeaways.

Best wishes from your friends at Tower for a healthy, happy, and prosperous new year! Remember to contact our Chief Compliance Officer Dan Anders with questions about any MSP compliance and MSA issues. Reach him at daniel.anders@towermsa.com.

Tower wishes you a happy holiday season filled with peace, joy and laughter! We hope you can connect with loved ones and have time to relax and recharge.

This is a time to reflect on the past and prepare for new opportunities in the upcoming year. As we do this, we are filled with gratitude for our clients and other partners. We cherish these strong relationships and deeply appreciate the opportunity to work closely with you.

May your holidays be merry, your New Year prosperous … and your settlements smooth!

 

The Centers for Medicare and Medicaid Services (CMS) has released 2023 data that provides insight into its Workers’ Compensation Medicare Set-Aside (WCMSA) reviews.  This is the second year in a row CMS has published such detailed metrics.

We thank CMS for publishing these annual statistics on the WCMSA review program.  They give interested parties a better understanding of CMS MSA review trends and a baseline for comparison.

The agency provided statistics for four years from 2020 through 2023 (CMS’s fiscal year ends Sept. 30). The data compared proposed MSA amounts with the CMS-recommended amounts, which we typically call the “approved” MSA amounts.

CMS MSA recommendations are up by 9%

In last year’s analysis of the CMS data, we speculated that the 17% decline over two years represented a trend away from CMS MSA submissions. However, this report shows a 9% increase in CMS MSA recommendations from 2022 to 2023*.  While total recommendations have not reached their 2020 level, there does not appear to be a significant move away from CMS MSA submissions.  Unfortunately, CMS does not provide pre-2020 data, which would give us a better picture of total pre-COVID MSA recommendations for comparison.

*In 2022, CMS completed 13,752 reviews; by the FY end of 2023, this had increased to 15,743.

Average MSA amounts have risen.

Along with more CMS MSA recommendations, the average CMS MSA amounts have gone up. The 2023 CMS average MSA amount of $86,453 is the highest in four years, exceeding the $84,563 in 2020.

There was also an increase in the variance between proposed and recommended MSA amounts.  While 2020-2022 ranged from 13-15%, the 2023 data showed a variance of nearly 22%. This translates into more counter-highers in response to MSA submissions to CMS.

 How Tower’s MSAs Stack Up

The release of these statistics allows Tower to compare its CMS-approved MSAs against all CMS-approved MSAs.

Average CMS-Approved MSA (2022 numbers):

CMS:  $81,572                                                 Tower:  $54,715

Tower’s CMS-approved MSAs are 33% lower than the CMS average approved MSA.

And if we isolate just the prescription drug component of the MSA:

Average CMS-approved Rx Amount in MSA (2022 numbers):

CMS: $20,776                                                  Tower:  $11,405

Tower is 45% lower than the CMS average for the prescription drug component.

These metrics show that cost reductions can be obtained when payers choose the CMS MSA approval process. Tower’s MSA allocation methodology and cost mitigation through interventions, such as our Physician Follow-up service, significantly reduce MSA allocations.

Simply put, this means millions of dollars in savings to our partner clients.

CMS Will Hold a Webinar on Civil Monetary Penalties and Section 111 Reporting

CMS recently announced it will host a webinar for Non-Group Health Plans (NGHPs) to discuss the “Certain Civil Money Penalties Final Rule” and enable Responsible Reporting Entities (RREs) to ask CMS questions directly. The webinar is scheduled for January 18 at 1:00 PM ET.  CMS advised that further details will be posted in the coming weeks. Tower will provide the information when available.

If you have any questions, please contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

 

 

The Centers for Medicare and Medicaid Services (CMS) has published a Frequently Asked Questions (FAQ) document to supplement its recently released Section 111 penalties rule.  There were a few crucial clarifications that we highlight below.

 Start Date for Reporting Data Subject to Penalties

Given the multiple dates provided in the final rule’s release, there was some confusion about the exact date that reported data would be subject to penalties. According to CMS’s FAQs, this date is October 11, 2024, the rule’s applicability date.  This means that only Total Payment Obligation to the Claimant (TPOC) and Ongoing Responsibility for Medicals (ORM) data reported on or after October 11, 2024 will be subject to penalties. In addition, the earliest that a Civil Monetary Penalty (CMP) can be imposed is October 11, 2025.  As such, the December 11, 2023 rule effective date has little relevance other than being the effective date of the rule.

Both TPOC and ORM on the Same Claim May be Subject to a Penalty

In CMS’s comments to the rule, it stated that “CMS has chosen to focus its definition of noncompliance solely on those situations where an entity has failed to provide its initial report of primary payment responsibility in a timely manner.”  This was interpreted as perhaps meaning that if ORM acceptance was reported timely, then a subsequent untimely TPOC report would not be subject to penalties.  This is not the case.  As CMS explains in the FAQs:

As a reminder, CMS considers ORM and TPOCs to be separate reporting obligations, and CMS will evaluate the timeliness of the ORM and TPOC reporting separately for the purposes of determining compliance.

Medicare Entitlement After ORM Acceptance

Another important question addressed in the FAQs is how CMS determines penalties when the claimant becomes a Medicare beneficiary after the date of injury.  CMS advised “the timeliness of reporting is based on the individual’s eligibility for or entitlement to Medicare.”  In short, if the claimant is a Medicare beneficiary on the date of injury, then that date is used to determine timely reporting. If not, and the claimant later becomes a Medicare beneficiary, then the Medicare entitlement date determines timely reporting.

To exemplify both of these rules, consider the following scenarios:

Scenario 1

A Medicare beneficiary claimant sustains an accepted work injury on March 1, 2024.  The Responsible Reporting Entity (RRE) fails to report ORM acceptance until October 2027.  Even though reported more than a year after the date of injury, the claim is not subject to penalties as both the date of injury and the claimant’s entitlement to Medicare occurred prior to October 11, 2024.

Scenario 2

A claimant who is not a Medicare beneficiary sustains an accepted work injury on March 1, 2024.  The claim remains open, and the claimant becomes a Medicare beneficiary on November 1, 2024.  The RRE fails to report ORM until October 2027.  The claim is subject to penalties (if chosen through the CMS random audit process) as while the date of injury is March 1, 2024, the Medicare entitlement date of November 1, 2024 occurred post-October 11, 2024.

To avoid penalties like this, always query claims to identify Medicare-eligible claimants and, when they are identified, timely report ORM or TPOC when all criteria are met for such reporting.

If you have any questions, please get in touch with Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.

In its November 13, 2023 webinar, the Centers for Medicare and Medicaid Services (CMS) announced plans to require the report of a Workers’ Compensation Medicare Set-Aside (WCMSA) amount concurrently with the report of Total Payment Obligation to the Claimant (TPOC) as part of Section 111 Mandatory Insurer Reporting.  CMS’s purpose in adding this requirement is to better identify when a Medicare beneficiary claimant has primary payer responsibility for future injury-related medical services.

A copy of a screenshot of the CMS webinar slides can be found here.

Below is a breakdown of the critical questions and answers provided by CMS:

Can CMS require reporting of WCMSAs through Section 111?

CMS cites Section 111 as its authority to specify the information to be reported to them to make an appropriate determination about coordination of benefits.

Does this requirement affect CMS-approved WCMSAs, non-CMS-approved WCMSAs, or both?

It is required for all WCMSAs, whether approved or non-CMS approved.  In short, if a claim is reportable for TPOC, then the WCMSA fields must be completed, even if it is to indicate a $0 MSA.  CMS advised that there are no low-dollar thresholds for reporting the WCMSA amount except those already incorporated into mandatory reporting, i.e., the $750 threshold for reporting physical trauma-based injuries.

What fields will be added to Section 111 reporting?

• MSA Amount
• MSA Period: If the MSA is more than $0, report the period of years the MSA amount is to cover.
• Lump/Annuity Indicator: If the MSA is more than $0, report whether the MSA is set up as a lump sum or structured annuity.
• Initial Deposit Amount: If the MSA is set-up as a structured annuity, provide the initial deposit amount.
• Anniversary (Annual) Deposit Amount: If annuity, the annual deposit amount.
• Case Control Number: If a CMS-approved MSA, the assigned Case Control Number (Optional field).
• Professional Administrator EIN: If there is a professional administrator for MSA

CMS stated there will be no changes to the Section 111 Response File Layout.  Further, errors about the WCMSA reported information will be returned as new soft or hard edits on the Section 111 NGHP Claim Response File according to current processing standards.  CMS advised additional details on this will be provided in the future.

What will CMS do with the WCMSA information it receives?

Regarding CMS-approved MSAs, CMS stated that while it has the approved amount on file, it can only move ahead with coordination of benefits (denial of payment for injury-related treatment) once it has been notified of a settlement, which includes amounts for future medical.

The final settlement documents must be uploaded to CMS after CMS MSA approval per the current rules.  However, this is sometimes not done post-settlement.  Consequently, requiring the reporting of the WCMSA amount through Section 111 reporting will act as another method by which CMS can initiate coordination of benefits based on the WCMSA.

Concerning non-CMS-approved MSAs, once notified, CMS will send the Medicare beneficiary claimant the same documentation a claimant currently receives for a CMS-approved MSA, which provides guidance and rules around MSA attestation and exhaustion.

When is the start date for reporting WCMSA information?

CMS has tentatively set the start date for reporting WCMSAs as January 2025.  The planned timeframe is for an updated file layout and error codes to be released in early 2024, with testing in the fall of 2024.

Will the WCMSA reporting requirement be retroactive?

CMS has not decided if the requirement will be retroactive.  We hope and will advocate that CMS implements this only on a prospective basis.

What if the MSA is for a non-Medicare beneficiary?

In some cases, MSAs are incorporated into settlements on individuals who are not yet Medicare beneficiaries but, for example, may be close to becoming Medicare eligible.  There is no Section 111 reporting requirement in these cases, thus no obligation to report a WCMSA amount.

How should RREs plan for this reporting change?

The addition of WCMSA fields for Section 111 reporting represents a technical and training challenge for RREs.  If claims adjusters currently enter data into Section 111 reporting fields on their claims systems, these new fields will need to be added, and adjusters will need to be trained on the procedures for entering information into these fields.

As we receive more information from CMS on the update to the reporting fields, we will provide guidance and recommendations to our Section 111 reporting clients.

Note, for Tower Section 111 reporting clients, we have your CMS-approved MSAs in our system to ensure these are reported appropriately at the time of TPOC reporting. We can also flag non-submit MSAs for reporting, but we will need certain additional information, such as whether a professional administrator is assigned to the MSA, to fully report.

If you have any comments or concerns, CMS asked that you email them to s111wcmsa@cms.hhs.gov. Also, please feel free to contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com.

 

On October 18 Tower’s Chief Compliance Officer Dan Anders and Chief Technology Officer Jesse Shade presented an informative webinar on Section 111 reporting and the final rule on Civil Monetary Penalties for untimely reporting. As shared in our post, these range from $250 per calendar day to $1,000 for each calendar day of non-compliance. Dan defined Section 111 reporting and covered the history of the penalty regulation before digging into the details and effects on payers. Here are some highlights:

Key dates

Penalties only apply to claims on and after December 11, 2023. Additionally, only 1,000 claims a year – from Group Health as well as Non-Group Health Plans – will be audited. The Centers for Medicare and Medicaid (CMS) will not issue penalties before October 11, 2024.

Dan advised that RREs should ensure that Ongoing Responsibility for Medicals (ORM) and Total Payment Obligation to the Claimant (TPOC) are reported in a timely fashion (within 135 days) in the quarterly file submission closest to the dates.

 Triggers for reporting

• Acceptance of ORM
• Termination of ORM
• Total Payment Obligation to the Claimant (TPOC)

Although all three milestones require reporting, there is no penalty for untimely reporting of termination of ORM. (However, if termination is not reported, an RRE could receive repayment demands after it is no longer liable to pay for medical treatment.)

Penalty process

The first penalty notification is informal and gives the Responsible Reporting Entity (RRE) 30 days to respond with any mitigating evidence.  If CMS doesn’t receive a response or accept the explanation, a formal notice will be issued.  RREs can pay the penalty or appeal it to an Administrative Law Judge.

Dan suggested examples of mitigating information and outlined the appeal process.  He also provided hypothetical cases that illustrate what could and would not risk one of these penalties.

Prevention

While the chance of receiving a penalty is relatively small, why risk it at all?  Compliance steps:

• Query for Medicare-eligible claimants every month
• Document attempts to obtain missing data (CMS prescribes the number and type of attempts.)
• Report ORM and TPOC within the next quarterly file submission

How Tower Helps

Jesse Shade demonstrated several powerful tools in Tower’s Section 111 portal that make it easier for RREs to comply with all aspects of Section 111 reporting.  Through the portal, RREs gain insight into individual claims or groups of claims and can:

• See errors that must be fixed before CMS can accept a file
• Drill down into specific error codes in order to correct them in the claims software
• Identify claims that could require ORM or TPOC reporting
• Find Medicare-eligible claims with open ORM that could be closed.
• Run and download reports to share with colleagues.

Your organization does not use Tower’s Section 111 reporting platform? Consider having Tower audit your Section 111 reporting program. This will identify the potential for penalties and reveal other issues that could lead to unwarranted conditional payment demands.

Finally, some Q&As

Who receives the notice of penalty?

 The RRE, of course.  We will also advocate that the reporting agent, Tower, receive a copy of the penalty notice, both informal and formal.

Are defense attorneys or other attorneys required to report Medicare beneficiaries?

There are no duties under the regulation for the attorney. This is specific to the RRE and claims handler. An attorney could be involved in tracking social security numbers or other claimant data for the RRE.

We have been advised that those enrolled in Medicaid are exempt from Section 111 reporting requirements. Is that correct?

That is correct; this only applies to Medicare.  However, if a claimant is a dual beneficiary enrolled in Medicare and Medicaid, then there would be a reporting obligation based on the Medicare enrollment.

What happens if the claimant doesn’t report the incident in a timely manner?

Interesting question.  In this case, the RRE could be reporting ORM for an injury that happened over a year earlier.  Or if a claim was initially denied but later accepted, perhaps due to a judicial decision, there could be an ORM reported more than a year after the date of injury. This seems like an explanation that CMS would accept and why the informal notice and response process is so important.

Do you still have questions about Section 111 reporting or a specific claim?  We are happy to help and like a challenge.  Please contact Daniel.Anders@TowerMSA.com.