Blog Archives

CMS Releases NGHP Beneficiary Appeals Guide

August 8, 2024

CMS recently released an NGHP Beneficiary Appeals Reference Guide. This valuable resource explains how a Medicare beneficiary claimant, their attorney or another authorized representative can work with the Benefits Coordination and Recovery Contractor (BCRC) to resolve Medicare conditional payment demands.

This informative document details how and when CMS recovers Medicare conditional payments from claimant Medicare beneficiaries in workers’ compensation, no-fault and liability claims.

Comprehensive Guide to Post-Settlement Medicare Conditional Payment Recovery and Appeals

The NGHP Beneficiary Appeals Guide is a helpful and comprehensive roadmap to the specifics of post-settlement Medicare conditional payment recovery from a claimant Medicare beneficiary. It covers the recovery process, pre-demand calculation options, the appeals process and payment methods. In addition, an appeal submission example and other sample letters are provided.

For cases involving conditional payment recovery from payers, CMS offers the NGHP Applicable Plan Appeals Reference Guide to the resolution of demands from the Commercial Repayment Center (CRC).

We commend CMS for creating this guide to help payers, attorneys, and Medicare beneficiaries better understand the Medicare conditional payment recovery processes and their rights and responsibilities during settlement.

As always, Tower is ready to help you with any conditional payment, Medicare Secondary Payer compliance, or Medicare Set-Aside issue. We especially enjoy your challenging cases! Contact Chief Compliance Officer Dan Anders at daniel.anders@towermsa.com.

New Updates to CMS’s WCMSA Reference Guide and Self Administration Tool Kit

August 7, 2024

The Centers for Medicare and Medicaid Services (CMS) recently updated its Workers Compensation Medicare Set-Aside (WCMSA) Reference Guide and WCMSA Self Administration Toolkit. These updates guide MSA administration when the beneficiary is enrolled in a Part C Medicare Advantage Plan or a Part D Prescription Drug Plan.

WCMSA Reference Guide Update

In its Version 4.1 of the WCMSA Reference Guide, CMS added an “Other Health Coverage,” section. Section 4.1.3 says:

… a WCMSA is still recommended when you have coverage through other private health insurance, the Veterans Administration, Medicare Advantage (Part C) or Medicare Prescription Drug Program (Part D)

CMS added the following as an explanation:

Other coverage could be canceled or you could elect not to use such a plan.

This makes sense for private health insurance, which a person may drop after becoming eligible for Medicare. Likewise, a veteran could treat at the VA initially and later seek treatment outside the VA.

However, CMS’s placement of Medicare Part C and D under “Other Health Coverage” is confusing. These are alternative delivery systems for Medicare benefits; a person must be Medicare-covered to use them. And there is no distinction between original Medicare and Parts C and D when it comes to the need for a WCMSA.

The guide makes clear distinctions regarding the coordination of benefits.

CMS notifies Part C and D plan sponsors that a WCMSA has been approved and instructs plan sponsors to conduct Medicare Secondary Payer (MSP) investigations. However, CMS does not relay WCMSA details to plan sponsors. Instead, CMS instructs plan sponsors to seek WCMSA coverage details from the WCMSA administrator as part of the plan sponsor’s investigation. When possible, Part C and D plan sponsors are required to avoid paying for expenses that should be covered by a WCMSA. (Emphasis added.)

It’s unclear why CMS does not provide WCMSA details to C and D plan sponsors as it does with original Medicare. Perhaps it’s a technology issue. From an MSP compliance standpoint, doing so would be beneficial to the plans and the injured worker as well as the taxpayers who pay for these plans.

A Quick Detour to Conditional Payments

After this section, CMS shifts from its WCMSA discussion to this statement on liens:

When a settlement is reached, the settlement details dictate who is responsible for ensuring Medicare (Parts A, B, C, and/or D) is repaid for any conditional payments associated with the WC illness or injury. If the settlement does not identify funds for past debt, CMS considers those debts up to the date of settlement to belong to the WC insurer.

Recovery may be sought from any party receiving inappropriate payment on behalf of the beneficiary.

This highlights the importance of including in the settlement terms which party is responsible for the resolution of Medicare conditional payments, whether from original Medicare or a Part C or D plan.

The Administrator Provides Treatment Details

Then the text returns to WCMSAs with this:

The administrator must provide details concerning treatments and medications used exclusively to treat a related illness or injury to the plan sponsor so the sponsor may avoid making primary payment in the future.

The MSA must either be self-administered by the injured worker or professionally administered by a third party, such as Ametros.

This last sentence in Section 4.1.3 is explained in more detail in the updated Self-Administration Toolkit, Version 1.6:

CMS will tell your Medicare Advantage or prescription drug plan that a WCMSA has been approved. Insurance plans are not given specific information about treatment and medications that should be covered by the WCMSA. You must tell your insurance plan sponsor any details concerning treatments and medications used exclusively to treat a related illness or injury, so they can avoid making primary payment in the future. CMS requires your plan to contact you or the administrator of your WCMSA to find out which expenses are covered by your WCMSA. The plan must avoid paying for expenses that are included in the WCMSA. The plan has a responsibility to recover any payments it made that should have been paid by the WCMSA. If you do not respond to your plan’s investigation efforts, your coverage may be delayed or cancelled.

If you are enrolled in a Medicare Advantage or prescription drug plan, please contact your plan to discuss your WCMSA, if you have not already done so.

Since CMS does not “relay WCMSA details to plan sponsors,” this appears to be how the Part C and D plans learn which diagnoses, treatments, and medications are included in the MSA.

WC Payers and CMS have made tremendous investments into Section 111 reporting and the WCMSA submission and approval processes. Therefore, it is disappointing that the MSA administrator is responsible for communicating with the Part C or D plan.

It remains unclear exactly how the MSA administrator will communicate with the Part C and D plans. Will the plan provide the administrator with a form or other instructions on how to notify the plans? How often should such communication occur?

All in all, this makes MSA self-administration even more difficult.

Tower does its best to help clients and partners navigate CMS changes. Our Chief Compliance Officer, Dan Anders, is available to answer questions and discuss how these updates affect you. Contact him at daniel.anders@towermsa.com.

CMS Section 111 Reference Guide Update Clarifies Date of Incident Reporting

July 15, 2024

New DOI Reporting Rules for Cumulative Injuries in Section 111 NGHP Guide

The new update of the Section 111 NGHP User Guide, Version 7.6, clarifies how to report the Date of Incident (DOI) in a Cumulative Injury. The Centers for Medicare and Medicaid Services added the following to Chapter III Policy Guidance, Chapter 2: Introduction and Important Terms:

Note: Cumulative injury refers to those categories of injuries that may persist or grow in severity, intensity, or pain but for which a formal diagnosis may not occur until a later date. Examples of cumulative injuries include, but are not limited to, carpal tunnel syndrome, or back pain that is not the result of an acute trauma. Exposure, ingestion, and inhalation injuries are not considered cumulative injuries for purposes of calculating DOI or any other reporting requirements.

Differentiating DOI Reporting for Cumulative Trauma vs. Exposure, Ingestion, or Inhalation Claims

We assume CMS added this note to ensure that RREs do not use the definition for DOI in cumulative trauma claims when they report an exposure, ingestion or inhalation claim, as there is indeed a difference.

Cumulative Trauma Claim DOI is defined as: The earlier of the date that treatment for any manifestation of the cumulative injury began, when such treatment preceded formal diagnosis, or the first date that formal diagnosis was made by a medical practitioner (for claims involving cumulative injury).

The guide defines the exposure, ingestion or implant DOI as:

The date of first exposure (for claims involving exposure, including; occupational disease)
The date of first ingestion (for claims involving ingestion)
The date of the implant or date of first implant, if there are multiple implants (for claims involving implant(s)

The NHGP update to Chapter IV Technical Information, Section 6.3.3 also included this addition regarding TIN/TN errors:

If your address fails validation with USPS, you must visit your local USPS office to correct this issue. Please make the correction immediately, as TN errors delay MSP records posting.

Per Section 6.6.5 of the guide:

RRE Address Validation

• RREs are encouraged to pre-validate insurer and recovery agent addresses using postal verification software or online tools available on the USPS website pages such as https://tools.usps.com/go/ZipLookupAction_input. RREs should try to use standard abbreviations and attempt to limit data submitted in these fields and adhere to USPS standards. The address validation enhancements in place will “scrub” addresses submitted on the TIN Reference File using USPS standards, and we recommend that RREs also attempt to meet these standards, to improve results. Although NGHP DDE reporters do not submit TIN Reference Files, they do submit the same TIN information online. It is recommended that DDE reporters also pre-validate RRE addresses.

CMS stressed:

Please address errors immediately, as TIN errors delay MSP record posting.

In short, make sure your TIN Reference File has a USPS-accepted address. If you are a Tower Section 111 reporting client, we will advise you if the file contains an error and recommend a correction and resubmission.

If you have any questions, please contact Dan Anders at daniel.anders@towermsa.com.

Section 111 Reporting for WCMSAs & Avoiding Civil Penalties

June 28, 2024

It’s time to get everything set up to accommodate new Section 111 reporting fields for WCMSAs. While compliance has long been required, Civil Money Penalties (CMPs) are real now.

Tower’s Chief Technology Officer Jesse Shade joined our Chief Compliance Officer Dan Anders for the “Premier Webinar: Get Ready for Section 111 Reporting Penalties and WCMSA Reporting” to help attendees do just that. Here are the highlights:

Important Section 111 penalty and WCMSA reporting dates

October 11, 2024
The date that CMS starts to make Responsible Reporting Entities (RREs) accountable for the timely reporting of ongoing responsibility for medicals (ORM) and of the Total Payment Obligation to the Claimant (TPOC). Any claims with ORM or TPOC on or after October 11, 2024, can be audited and subject to penalties.

April 1, 2025
CMS requires the reporting of WCMSA information when a TPOC is reported

October 11, 2025
Date that CMS starts its compliance review process.

April 1, 2026
CMS begins Section 111 reporting audits.

About those penalties

No penalties will be issued for claims that are reported within one year of the date of acceptance of ORM or the TPOC date. And no claims with ORM or TPOC dates prior to October 11, 2024, will be reviewed.

If a claim is not reported within one year, the RRE can incur penalties of $357 per calendar day. This per-day penalty increases to $1,428 if it’s not reported for three years. (These are 2024 inflation-adjusted rates.)

The good news is that CMS caps the amount of a penalty for a single instance of noncompliance by a non-group health RRE. The bad news is that cap is $365,000!

In the somewhat good news department, CMS will randomly select only 1,000 claims to audit each year and audit 250 claims every quarter. Additionally, the agency will randomly select claims from group health as well as non-group health plan (NGHP) claims from workers’ compensation, liability and no-fault programs. This greatly mitigates your risk of an audit even if you have instances of late ORM or TPOC reporting.

How does CMS notify RREs of penalties?

CMS first emails an informal notice, so it is important to keep contact information updated in the Section 111 Profile. This initial notice allows the RRE to present mitigating evidence and this must be presented within 30 days.

Examples of the type of evidence to submit include: ORM was not reported because the claim was under investigation OR a good-faith effort was made to obtain claimant information, such as a social security number, but the claimant refused to provide it or did not respond. (See CMS Section 111 Penalties Rule Focuses on Untimely Reporting – Tower MSA for details on “good-faith efforts” to establish Medicare eligibility.)

If the RRE does not respond to the informal notice or CMS rejects the explanation, the agency mails a formal written notice. At this point, an RRE either needs to pay a fine or appeal to an administrative law judge within 60 days.

WCMSA Reporting Fields

Jesse Shade reviewed the upcoming changes CMS will implement to collect additional information on WCMSAs through Section 111 reporting. New fields and the information for them were covered in this post.

Tower smooths the transition for its Section 111 clients.

Jesse also described Tower’s IT efforts to make things as easy as possible for our Section 111 reporting clients. Our goal is to improve your ability to monitor the pivotal events in a claim.

The first step for Tower reporting clients is adding the new WCMSA fields to the end of your current claim input file. Once the fields are added to the feed file, testing will be scheduled to confirm that the data is properly transmitted to Tower. Tower will, in turn, participate in a testing period with CMS that begins in October.

The additional fields will require those who enter the Section 111 reporting information to be trained on when to enter the WCMSA date, what date to enter, and how to enter the data.

Additionally, Tower will highlight in our MSA delivery correspondence the importance of completing this information at the time of settlement.

Tower will continue to provide comprehensive reports to our Section 111 reporting clients, ensuring the accuracy of the data reported.

Our commitment is to make this transition easy and seamless for everyone involved and we will customize systems where needed so the process works for all our clients.

Practices that protect RREs from penalties

Dan advised clients to do the following to maintain compliance with the reporting rules:

Query claims to identify Medicare beneficiaries monthly and document when a social security number cannot be obtained.
Report ORM acceptance and TPOCs on the next quarterly submission.
Correct errors in reporting data to avoid report rejection (if they reject a submission, it will be considered untimely if not corrected within the reporting deadline).
When WCMSA reporting begins, make sure these fields are completed anytime a TPOC is reported.

The webinar also provided several examples of how ORM and TPOC penalties could work and how they could be mitigated. Slides and access to the recorded webinar can be requested from Dan Anders, daniel.anders@towermsa.com.

Tower’s proactive audit

To ensure your organization’s readiness for the coming audits and penalties, have Tower audit your processes, policies and systems to see if there are any holes in your compliance. Not only will we identify errors and other issues that could lead to penalties, but we also help you fix issues that lead to them. For more information on our Section 111 audit offer, please contact hany.abdelsayed@towermsa.com.

Tower’s Physician Follow-Up Service Kicks Costly SCS Out of MSA

June 20, 2024

Save-Medicare-Set-Asides-with-Tower's-Physician-Follow-Up-service.

Nothing can stall settlement faster than a Medicare Set-Aside (MSA) that includes an unnecessary or unwanted medical procedure. Procedures like surgeries, spinal cord stimulators (SCSs), and intrathecal pain pumps significantly raise the costs of MSA allocations. Fortunately, Tower’s client partners have access to our complimentary Physician Follow-up service that Save on MSAs.

In a recent case, this service successfully removed a costly SCS from the MSA, resulting in a savings of $132,232.

Challenges with SCS Trial Inclusion in MSAs: Addressing Worker Reluctance and CMS Requirements

A worker who had suffered a low back injury was advised by his neurosurgeon and pain management physician to consider an SCS trial. A review of treatment records showed that the injured worker was very anxious about the procedure, and a psychological evaluation revealed a diagnosis of major depressive disorder.

Despite the worker’s reluctance to undergo the procedure, CMS will include it in the MSA, assuming that the worker may change their mind. Tower drafted an initial MSA to include the SCS for a total allocation of $157,500.

Successfully Removing SCS from MSA with Physician Statements: Tower’s Approach

The injured worker’s resistance to the procedure and results of the psych evaluation indicated he would not be a suitable candidate for an SCS. Therefore, we recommended that our Physician Follow-up service obtain statements from both physicians that confirmed the SCS is no longer part of the treatment plan. (If only one physician had provided a statement, CMS would likely keep the SCS in the MSA).

After client approval, in compliance with this jurisdiction’s regulations, Tower notified the plaintiff’s attorney of our intention to communicate with the injured worker’s providers. We then contacted the neurosurgeon and pain management specialist and provided them drafts of physician statements that confirmed the SCS is no longer a treatment option.

While it took several weeks of persistent follow-up with the physicians’ offices, Tower successfully obtained both signed statements.

Efficient MSA Revision: Tower Achieves Significant Cost Reduction and Quick CMS Approval

Tower revised the MSA down from $157,500 to $25,268 and submitted it to CMS. CMS approved the MSA within two weeks for the proposed amount.

In response, Tower’s client said, “Great job, Tower! I am so thankful for our partnership and truly appreciate your hard work and persistence. $132k in savings!!! Woohoo!”

The defense attorney said, “you guys work some real magic here, bravo!”

It’s more methodology than magic, but we often find opportunities to reduce the allocation or mitigate potential increases from CMS review when we draft an MSA. Vague references to potential future procedures mean these costs will be included in the MSA. CMS’s exacting review process requires explicit confirmation of the last dates of service and ongoing treatment and medications.

At no extra charge, Tower contacts physicians, clarifies treatment, drafts physician statements, and obtains medical providers’ signatures to document dates of treatment and ongoing and future medical care. This service paves the way to quick CMS MSA approval and mitigates the potential for unexpected increases.

To learn more about our Physician Follow-up service, please get in touch with Hany Abdelsayed at 888.331.4941 or hany.abdelsayed@towermsa.com.

How to Manage Medicare Set-Asides: Tips from Dan Anders

May 29, 2024

Our Chief Compliance Officer Dan Anders learned how to write Medicare Set-Asides (MSA) the hard way through trial and error in the days before the Centers for Medicare and Medicaid published complete guidelines. Even now, the manuals and regulations don’t cover every detail.

And with MSAs details matter. Proper documentation, down to the way the claimant signs and initials their consent form, is essential. Dan compiled some tips for managing MSAs with CMS in his May 21 Leaders Speak article for WorkCompWire. These are among the topics covered:

Rated ages

The article highlights the use of rated ages as a way to calculate a fair allocation for the MSA. Briefly, if an injured worker has comorbidities that will likely reduce their longevity, a rated age can reduce the allocation of the MSA.

How to respond to a dreaded Development Letter from CMS

Dan tells readers how to respond to a CMS Development Letter, which CMS sends when it needs additional information to review submitted MSA. These letters usually request updated treatment records, complete claim payment history of medical, indemnity and expenses, or a document that clearly outlines all the dates of injuries, all carriers, and all accepted and denied body parts.

Development letters can be avoided with the submission of all the correct documents with the MSA. Some submissions provide an Independent Medical Evaluation or Qualified Medical Evaluator report in lieu of medical records. IMEs, QMEs and similar evaluations may influence a decision, but they cannot replace treatment records. And CMS wants ALL the injury-related records even if workers’ compensation did not pay for the treatment.

When to request a Re-Review

Dan also explains how to handle the Re-Review Appeal process. CMS can make mistakes when issuing counter-highers. He cites several common mistakes, including incorrect prescription drug pricing, misinterpretation of medical records, and using the wrong fee schedule. Always analyze counter-highers for potential errors and consider taking advantage of this appeal.

Tower is here to help manage Medicare Set-Asides

Read the article here and remember that Tower consults with its clients on every aspect of MSA submission and other Medicare Secondary Payer issues. Whether you’re a client yet or not, Dan is available to discuss issues you encounter with your MSAs. Contact him at daniel.anders@towermsa.com.

Avoid Penalties: Tower’s Section 111 Reporting Audit Service

May 16, 2024

Person preforming Section 111 reporting audit service

Tower’s Section 111 Reporting Audit Service Can Help You Fix Systemic Issues and Avoid Penalties. Workers’ compensation payers and other Responsible Reporting Entities (RREs) have a little over five months to get their Section 111 reporting houses in order. And Tower’s Section 111 reporting audit service is here to help you clean things up.

Section 111 reporting – a bit of background

Starting October 11, 2024, RREs, which are workers’ compensation plans, liability insurance (including self-insurance) and no-fault insurance) will be held accountable for the timely reporting of Medicare beneficiary claimants where ongoing responsibility for medicals (ORM) has been accepted or where a Total Payment Obligation to the Claimant (TPOC) has occurred. Civil Money Penalties (CMPs) for untimely reporting of ORM acceptance or TPOC can be thousands of dollars on a single claim.

Three reasons to have Tower audit your Section 111 reporting

Catch the type of errors, omissions and inconsistencies that could trigger thousands of dollars in penalties.
Eliminate systemic flaws that lead to time-consuming and unnecessary conditional payment demands
Help you correct human and technology processes and procedures so you can avoid future reporting errors

What’s involved in the audit?

You provide a set of claim input, claim response and query response files for an agreed-upon period.
Our compliance experts examine this data for issues that can prevent proper and timely reporting of:

Acceptance of ongoing responsibility for medicals (ORM)
Termination of ORM
TPOC

We also look for:

Errors in claim input file data
CMS-identified errors and flags in claim response files
Consistency of your policies and procedures with CMS Section 111 reporting standards

You’ll receive an audit report and consultation. The report will identify actual or potential errors, omissions and inconsistencies and recommend corrective actions. You’re not left on your own! Tower collaborates with you during the audit and guides the implementation of process and policy changes. As with all our services, we answer your questions and consult with you every step of the way.

How does this help conditional payment resolutions?

If payers or their RREs fail to report ORM termination through Section 111 reporting, Medicare assumes the payer is still responsible for injury-related medical bills. The agency will either deny payment on these or pay them and seek reimbursement through the conditional payment process. The audit identifies TPOC/ORM/Section 111 reporting issues and shows you how to fix them to prevent unnecessary conditional payment demands.

Tower’s Section 111 Audit provides quick fixes and policy and process changes for long-term Section 111 reporting compliance assurance.

Next steps? Contact Hany Abdelsayed, our EVP of Strategic Services at
hany.abdelsayed@towermsa.com or 888.331.4941.

Premier Webinar: Get Ready for Section 111 Reporting Penalties and WCMSA Reporting

May 3, 2024

CMS Announces Section 111 Mandatory Insurer Reporting Changes: Penalties and New WCMSA Requirements

The Centers for Medicare and Medicaid Services (CMS) has released several announcements regarding Section 111 Mandatory Insurer Reporting over recent months. Some relate to Section 111 penalties and some to the new requirement to add Workers’ Compensation MSAs to Section 111 reporting.

Timely and accurate Section 111 reporting is essential if you want to avoid penalties. And WCMSA reporting will introduce new tasks for claims professionals and potentially affect how WC cases with Medicare beneficiary claimants are settled.

To help you and your organization prepare for these changes

Tower will hold a “Get Ready for Section 111 Reporting Penalties and WCMSA Reporting” webinar on May 22.

Please join Tower’s Chief Compliance Officer Dan Anders and Chief Technology Officer Jesse Shade for this valuable, instructional session. Scheduled for Wednesday, May 22, 2024, at 2 pm ET, the hour-long webinar will address:

Criteria and timeline for the implementation of Section 111 Reporting penalties.
Practices to mitigate and eliminate the potential for penalties.
How a Section 111 reporting audit can identify errors, blind spots and recommend corrective actions to your systems and processes.
Criteria and timeline for Workers Compensation MSA reporting.
Implication of WCMSA reporting for claims professionals, attorneys, and settling parties.

A Q&A session will follow the presentation, and you can provide questions ahead of time at registration. Please click the link below and register today!

CMS Moves Start Date for WCMSA Reporting to April 2025

April 23, 2024

CMS delays start date for Section 111 reporting of WCMSAs to April 2025 and announces new webinar for Q&A

During last week’s webinar, the Centers for Medicare and Medicaid Services (CMS) announced an extension of the start date for Section 111 reporting of WCMSAs from January 2025 to April 4, 2025.

(Due to technical difficulties with the April 16 webcast, CMS has scheduled another webinar for Q&A this Thursday, April 25, 2024, at 2:30 ET. Details on the webinar are here.

Remember, CMS requires Section 111 reporting of WCMSAs of any MSA amount, even if $0. These amounts must be reported whether they are CMS-approved MSAs or not.

CMS details new reporting guidelines and start date for Section 111 WCMSA Implementation

CMS reiterated several points that had been detailed in a prior webinar and through the recent Section 111 User Guide update. Please review CMS Updates Section 111 NGHP User Guide and WCMSA Reference Guide for this information. New points are below:

The start date for WCMSA reporting was changed from January 2025 to April 4, 2025, to give Responsible Reporting Entities (RREs) more time to make the needed changes to their reporting processes.
Testing of the new fields will be available beginning on October 7, 2024.
All WCMSA fields except Field 43 (Professional Administration EIN) will result in “hard” errors if reported incorrectly. Hard errors cause the TPOC report to be rejected, which can in turn cause the report to be untimely if it is not corrected promptly.
As such, hard errors may result in the imposition of civil money penalties (CMPs) although CMS will not impose a CMP for two reporting periods after implementation of WCMSA reporting. In other words, only records on or after October 15, 2025, and with a reportable MSA are subject to a CMP.
If an RRE fails to report an MSA, CMS may utilize all available statutory and regulatory options to recover mistakenly made payments, including under the False Claims Act.
No changes are made as to what constitutes a reportable TPOC. If a TPOC is reportable, then the WCMSA fields must be completed. If it is not reportable, such as when the WC settlement is $750 or less, then the WCMSA fields are not completed.
If multiple defendants are parties to a single settlement, they must report the total TPOC amount (and not their “share”) and the total MSA amount.
The Section 111 reporting process is not intended to replace the submission of settlement documents to CMS following the settlement of a claim with a CMS-approved MSA. (Final settlement documents should always be sent to Tower for upload to CMS.)
Receipt of the MSA report through the Section 111 reporting process will allow CMS to send information to the beneficiary on the attestation and exhaustion process. (Currently this is not done for most self-administered non-submit MSAs).

CMS outlines impact of “W” records in common working file (CWF) for MSA reporting

CMS also explained that once the MSA is reported, a “W” record will be posted in the Common Working File (CWF), which prevents payments of medical services related to the reported diagnosis codes. The CWF is part of CMS’s system to accurately coordinate benefits, so Medicare does not make payment when another “primary payer” is available.

A copy of the webinar slides can be found here.

Please contact Dan Anders at daniel.anders@towermsa.com with any questions.

CMS Updates Section 111 NGHP User Guide and WCMSA Reference Guide

April 5, 2024

CMS Releases Updates to MMSEA Section 111 NGHP User Guide and WCMSA Reference Guide

The Centers for Medicare and Medicaid Services (CMS) began April with updates to two of its popular user guides, the MMSEA Section 111 NGHP User Guide and the WCMSA Reference Guide. Notably, the NGHP User Guide, version 7.5, now includes details on the requirements to report WCMSA amounts with other relevant data. These will need to be reported as of April 4, 2025.

The NGHP User Guide, Section 6.5.1.1 of Chapter III: Policy Guidance, was updated to state:

For workers’ compensation records submitted on a production file with a TPOC date on or after April 4, 2025, Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) must be reported.

CMS also updated Chapter IV: Technical Information with similar language.

CMS Revisions to WCMSA Reporting Fields in Chapter V: Appendices

Additionally, CMS updated Chapter V: Appendices to identify the fields that will be added to the Claim Input File Detail for WCMSA reporting:

Field 37 – MSA Amount: This will be either $0 or an amount greater than $0. If an annuity is used, then the “total payout” is reported.
Field 38 – 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.
Field 39 – 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.
Field 40 – Initial Deposit Amount: If an annuity, then the MSA seed amount is reported.
Field 41 – Anniversary Deposit Amount: If an annuity, then the amount of the annual payments.
Field 42 – 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.
Field 43 – Professional Administrator EIN: Enter the Employer Identification Number of the professional administrator here if there is one. If this EIN is not provided, the “case administrator” defaults to the beneficiary. If the EIN 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 provided a table of error codes for errors identified in the above-reported information.

Responsible Reporting Entities (RREs) can start testing these new fields on October 7, 2024. For further details, see the Tower article, CMS Sets Date for Start of Section 111 WCMSA Reporting.

CMS also incorporated the following notice into the NGHP User Guide:

As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).

The $750 reporting threshold has been in place for several years.

CMS included minor updates to the WCMSA Reference Guide, version 4.0

Specifically, CMS added:

Instruction specific to beneficiaries has been added to encourage them to use their Medicare.gov access to the portal for the most efficient method of submitting attestations (Sections 11.1.1 and 17.5).

For further information on electronic reporting of attestations, see the above-referenced sections in the guide or the Tower article, CMS Adds Electronic Submission Option for MSA Attestations.

CMS also amended the link in Section 10.3 to reflect the most recent CDC Life Table link. The life tables are used to determine life expectancy for calculation of the MSA.