The PAID Act: Implementation and Implications for Claims Handling

October 15, 2021

Chalk board depicting what the PAID Act covers

Thanks to the Provide Accurate Information Directly (PAID) Act effective December 11, 2021, payers will have access to Medicare beneficiary enrollment status in Medicare Part C (Medicare Advantage [MA]) plans or Part D (prescription drug) plans. Enrollment information will be provided through the Section 111 query response file for the past three years.

Historically, workers’ compensation, liability, and no-fault insurance plans have had a difficult time trying to determine a Medicare beneficiary’s enrollment status in such plans as the current query response file only provides a yes or now as to whether the individual is enrolled in Medicare.  However, as close to 40% of Medicare beneficiaries are enrolled in a Part C plan and over 70% are enrolled in a Part D plan, the potential for these plans to seek reimbursement from both payer and/or claimant is significant.

Currently, payers must ask the claimant to voluntarily provide Part C and D plan information which sometimes is never provided or is provided, but incomplete or inaccurate.  Notably, Medicare beneficiaries can change plans every year, meaning in some cases many plans may have reimbursement rights over the course of a claim.

Of course, Medicare already shares Section 111 reporting data with the Part C and D plans, thus giving them the ability to seek reimbursement against a payer who may have no idea the claimant is enrolled in such a plan until they receive a demand for payment.

Great, But Now What? 

Tower’s September 15 “How-to Guide for PAID Act Implementation” webinar explained how the PAID Act affects payers, the differences in recovery processes, and the new reports Tower is creating to make life easier for its clients. If you missed the webinar, contact me at Daniel.Anders@towermsa.com to request the link because there’s a lot of information.

The Section 111 query response data received from the Benefits Coordination & Recovery Center (BCRC) is changing in a big way.  There are 244 new data fields. Parts A, B, C, and D will have the most recent effective dates and termination dates. Part C and D will have most recent and previous plan(s) data, up to three years of data. This will include not only the plan name, but also contract number, enrollment date, termination date, benefit package number and plan address.

Payers can receive and store this data themselves or, for Tower reporting clients, we will store it for our clients who can then obtain the data via Tower’s Section 111 portal.  In other words, it is the payer’s choice whether to receive this information.

Tower will also create PAID Act-specific reports around the new data, accessible through our S111 Management dashboard. These will be:

  • Most Recent Medicare Effective and Termination Parts A, B, C, and D
  • All Part C data
  • All Part D data

Now, the Centers for Medicare and Medicaid Services will only provide the past three years of data, but Tower will store data beyond three years for use by our clients on claims which remain outstanding past that timeframe.

Handling Recovery

Based on the MSP statute and regulations and court decisions the Part C and D plans have a right of recovery against the primary plan and all those who receive payment from that primary plan, such as the claimant and the claimant’s attorney.  In some cases, a claim for reimbursement will be issued by the Part C or D plan without initiating an inquiry. Payers should use the contact information from the Section 111 data to initiate a query with the plan(s) to determine whether they have a reimbursement claim.

There are several differences among CMS recovery through Part A and B (Original Medicare) and Parts C and D recovery.

  • Part C and D plans cannot access the Medicare Secondary Payer Recovery Portal (MSPRP)
  • Debt collection is not split into two recovery contractors (Commercial Repayment Center (CRC) and BCRC), however, these plans might contract out their recovery efforts.
  • The C and D plans also cannot refer debts to the U.S. Treasury Department; they must file suit instead.
  • In our experience, Part D and C plans have significantly less unrelated charges on their claims for reimbursement compared to CRC and BCRC.
  • Appeal rights are only held by the claimant unlike with Original Medicare conditional payment demands where an appeal right is also held by the payer.

Considering the above, on balance, while identifying the plan and obtaining the reimbursement claim may be a bit more difficult, Part C and D claims for reimbursement tend to be easier to resolve compared to demands from CMS’s recovery contractors.

Guidance for Addressing Part C and D Reimbursement

The following is recommended to properly resolve Part C and D reimbursement claims at time of settlement:

  • Identify if the claimant is a Medicare beneficiary and enrolled in a Part C or D Plan
  • Identify If the claimant was ever enrolled in traditional Medicare; if so investigate conditional payments with CRC and BCRC
  • Investigate with Part C or D plan whether it is seeking reimbursement and obtain a letter itemizing reimbursement claims.
  • Negotiate with Part C or D plan to remove charges unrelated to work injury or where there is a reasonable basis to dispute. These plans largely use the same dispute and appeal criteria as CRC/BCRC
  • Contact plan at time of settlement to confirm final amount owed
  • Resolve case with clear understanding of how plan will be reimbursed

Keep in mind that the PAID Act in no way changes Part C and D reimbursement rights nor puts any additional obligations on these plans that did not already exist prior to its passage.  Nonetheless, access to plan information by payers will undoubtedly lead to a greater emphasis on contact with the plan prior to settlement.  Payers should make use of this data to query the plan and identify and resolve reimbursement claims at the time of settlement.

Whether you’re ready to implement the PAID Act or not, Tower is.  In fact, we’re in front of it, building out our systems, creating reports to add to our year-old S111 Management Dashboard. We’ve been watching pending legislation and posting on it all along, thinking about how it could affect you and planning for the future.

As always, if you have questions about the PAID Act or anything else MSP or MSA related, please contact me at Daniel.Anders@towermsa.com or 847-946-2880.

There’s no better time to let Tower manage your Section 111 reporting. Contact Hany Abdelsayed for the details.   Hany Abdelsayed, hany.abdelsayed@towermsa.com, (916) 878-8062.

PAID Act Implementation How-to Guide Webinar, Sept. 15

August 18, 2021

Details of PAID Act Webinar with photo of Dan Anders & Jesse Shade

Join Tower’s Webinar for PAID Act implementation “How to Guide”  on September 15th.

Because of the PAID Act, self-insured employers, insurers and other non-group health plans will finally have access to Medicare Part C Advantage Plan and Part D prescription drug plan information for Medicare beneficiary claimants, starting December 11, 2021. The Centers for Medicare and Medicaid Services (CMS) will provide the data through the Section 111 reporting query process.

While the implementation of these PAID Act requirements is a technical one, it gives rise to many policy questions as to what payers are required to do once they have this data.

Join Dan Anders, Chief Compliance Officer and Jesse Shade, Chief Technology Officer on Wednesday, September 15 at 2:00 PM ET, for a webinar which will tackle both the technical and policy implications around the PAID Act.  Topics include:

  • The Part C and Part D plan identification problem the PAID Act is designed to resolve.
  • Technical changes needed to receive this new CMS data come December.
  • Best practices for handling Part C and D plan data to resolve reimbursement claims from these plans.

Dan and Jesse will describe the steps Tower has taken to ensure our Section 111 reporting clients have a seamless transition to receive the PAID Act data and how Tower can work with you to identify and resolve Part C and D plan reimbursement claims.

A Q&A session will follow the presentation.  Please click the link below and register today!

REGISTER HERE

Related Prior Posts:

PAID Act Becomes Law

CMS to Host Webinar on PAID Act Implementation and Upcoming Testing

August 12, 2021

Red Medicare button on a keyboard to illustrate Medicare conditional payment.

On Thursday, September 9, 2021, at 1 p.m. ET the Centers for Medicare and Medicaid Services (CMS) will be hosting a second webinar on the implementation of the Provide Accurate Information Directly (PAID) Act.  Per the notice:

CMS will be hosting a second webinar regarding the impacts to Section 111 Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) related to the PAID Act, which was signed into law on December 11, 2020. The intention of the PAID Act is to help NGHP RREs better coordinate benefits by providing beneficiary Part C and Part D enrollment information via updates to the Section 111 Query Response File. These changes will go into effect on December 11, 2021. This webinar will offer important PAID Act reminders and focus on the details of the upcoming testing period, which will begin on September 13, 2021. The webinar presentation will be followed by a live question and answer session with staff from CMS and the Benefits Coordination & Recovery Center.

Check out slides from the first CMS Provide Accurate Information Directly Act webinar.

If you are a Tower Section 111 reporting client, we recently provided a draft query response file layout.  This layout incorporates the additional fields required to receive Part C and Part D enrollment information and Part A and Part B effective and termination (if applicable) dates.  Tower will initiate testing with the BCRC in September and make changes, if any, to the final file layout before the December 2021 implementation.  Additionally, Tower’s next quarterly webinar (date and time to be announced soon), will address PAID Act implementation and best practices for resolving reimbursement claims from Part C Medicare Advantage and Part D Prescription Drug Plans.

We encourage anyone involved in the Section 111 reporting process to attend the CMS webinar.

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

Related Prior Posts:

CMS: PAID Act Implementation Guidance & New ORM Termination Option

PAID Act Becomes Law

 

CMS to Host PAID Act Webinar

May 25, 2021

Red Medicare button on a keyboard to illustrate Medicare conditional payment.

On Wednesday, June 23 at 1 p.m. ET the Centers for Medicare and Medicaid Services (CMS) will be hosting a webinar on the implementation of the Provide Accurate Information Directly (PAID) Act.  Per the notice:

CMS will be hosting a webinar to discuss upcoming impacts to Section 111 Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) related to the PAID Act, which was signed into law on December 11, 2020. The intention of the PAID Act is to help NGHP Responsible Reporting Entities better coordinate benefits by providing additional beneficiary Part C and Part D enrollment information. This webinar will cover what the PAID Act is, details of the NGHP Section 111 Query Response File changes, information on the scheduled testing period and implementation timeframes. The webinar will also be followed by a live question and answer session with staff from CMS and the Benefits Coordination & Recovery Center.

Further background on the PAID Act can be found in Tower’s article: PAID Act Becomes Law

We encourage anyone involved in the Section 111 reporting process to attend the webinar.  Tower will provide a post-webinar summary.

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

Dan Anders in WorkCompWire: Avoiding Section 111 Reporting Penalties

May 11, 2021

bullhorn illustration alerting you to avoid reporting penalties

With a name like “Mandatory Insurer Reporting” and potential reporting penalties of up to $1,000 per day per injured worker, one would think payers would take Section 111 reporting penalties pretty seriously. But since these penalties have never been enforced, avoidance of penalties has not been a top concern.

It looks like Section 111 penalties could be coming soon, though. The Centers for Medicare and Medicaid Services (CMS) positioned itself to implement them by proposing specific regulations last year. The agency solicited comments from stakeholders last April and could publish final regulations at any time.

Tower’s Chief Compliance Officer, Dan Anders, wrote an article in this week’s WorkCompWire Leaders Speak series, Plan Now to Avoid Pending Medicare Reporting Penalties, that recaps the history of Section 111 reporting and outlines reporting errors and CMS’s proposed penalties. And, unlike many articles that just tell you what CMS says, Dan’s piece recommends ways readers can steer clear of potential errors and problems.

Speaking of steering clear, if you’re not already using Tower’s S111 Management Dashboard, ask Hany Abdelsayed to take you for a test drive. Contact Hany at hany.abdelsayed@towermsa.com or 916-878-8062.

For more details on Section 111 reporting and Civil Money Penalties, check out Dan’s prior posts:

You can always contact Dan with any questions or concerns about this or any other compliance or MSA issues. He can be reached at daniel.anders@towermsa.com.

CMS Updates Section 111 Model Language Form

April 26, 2021

Man signing a document to illustrate CMS updates to Section 111 Model Language Form

Recently, the Section 111 Model Language form was updated by the Centers for Medicare and Medicaid Services (CMS), The form is used by Responsible Reporting Entities (RREs) to collect the Medicare Beneficiary Identifier (MBI) and/or a Social Security Number (SSN) from claimants.  The SSN or MBI, along with the claimant’s First and Last Name, Gender, and Date of Birth, are needed by the RRE to query CMS to determine whether the claimant is a Medicare beneficiary for Section 111 Mandatory Insurer Reporting purposes.

The most notable change to the form is that the Section I language was revised from “Are you presently, or have you ever been, enrolled in Medicare Part A or Part B?” to “Are you presently, or have you ever been, enrolled in Medicare?” We assume this language was modified because the claimant’s enrollment in Parts A, B, or C (which isn’t even mentioned) is irrelevant for purposes of Section 111 reporting. The simpler language, just asking for Medicare enrollment status, should avoid confusion that may have arisen from the prior language.

Practical Implications of the Section 111 Model Language form

As we wait for CMS to issue final rules around mandatory insurer reporting penalties, it is important for RREs and those administering claims for RREs to collect this identifying information or document their efforts to collect it by using this model language.  As we discussed in CMS Issues Proposed Rule for Mandatory Insurer Reporting Penalties, RREs will have a safe harbor from reporting penalties if they document good faith efforts to attempt to obtain an MBI or SSN from the claimant, and this model form will help document those efforts.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with comments or questions.

Related Posts

Section 111 Reporting

Dan Anders in WorkCompWire: Avoiding Section 111 Reporting Penalties

 

CMS Section 111 Mandatory Insurer Reporting Webinar Recap

April 7, 2021

man on keyboard for Section 111 Mandatory Insurer Reporting

Leaders from the Centers for Medicaid and Medicare Services (CMS) Division of MSP Program Operations, Commercial Repayment Center (CRC), and Benefits Coordination and Recovery Center (BCRC) held an April 1 webinar on the intersection of the BCRC and CRC in Section 111 Mandatory Insurer Reporting and the resolution of Medicare conditional payments.

While mostly a Q&A format, the webinar unveiled a new CMS/BCRC policy for reporting partial settlement of medical when Ongoing Responsibility for Medical (ORM) ends for certain diagnoses and continues for others. Set to rollout in June, the new reporting policy provides for three scenarios:

  • Partial settlement of medical prior to initial reporting

Scenario:  Claimant is identified as a Medicare beneficiary which triggers the requirement to report ORM and/or Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process.  Both ORM and TPOC are for the same insurance type, policy, and claim number.  The only difference is the accepted and denied diagnoses on the claim.  The parties agree to a partial settlement for the denied diagnoses and leave the accepted diagnoses open on the claim.

Problem:  How to report a partial settlement of the denied diagnoses and still report ORM for the accepted diagnoses.

 CMS Solution:  CMS’s solution is to submit two add records. Specifically, one record will be added for ORM that will describe all of the diagnoses that have been accepted for ORM.  ORM will be ‘Y’ with no TPOC date or amounts.  A second record will be added for TPOC which will describe all of the denied diagnoses that are being settled.  ORM will be ‘N’ with a TPOC date and amount.

  • Partial settlement of medical post initial reporting

Scenario:  A claim with multiple diagnoses was reported for ORM through the Section 111 Mandatory Insurer Reporting process.  The parties agree to a settlement for certain diagnoses while keeping ORM open for other diagnoses.

Problem:  How to report a partial settlement for certain diagnoses while keeping ORM open for the non-settled diagnoses.

CMS Solution:  CMS’s solution is to submit one update record and one add record.  The update record will remove the diagnoses that are subject to the partial settlement and keep the diagnoses codes where ORM continues.  Then, an add record with the TPOC date, amount and diagnoses codes that are subject to the partial settlement will be submitted.  ORM will remain “N” in the add record.

  • Partial ORM closure with no settlement

Scenario:  Acceptance of ORM is initially reported though the Section 111 Mandatory Insurer Reporting process with multiple diagnoses.  Subsequent to this initial report, there is a basis to terminate one or more of the initially accepted diagnoses, but not all of the diagnoses.  This is not a situation where a partial settlement has occurred, rather there is a basis to terminate one or more diagnoses absent a settlement.  For example, a claimant’s cardiac condition was exacerbated as a result of a fall and the medical providers confirm resolution of the exacerbation. While the carrier continues to accept the orthopedic condition, the ORM can end for the cardiac diagnosis.

Problem:  How to end ORM for one or more diagnoses while keeping it open for other diagnoses.

CMS Solution:  CMS’s solution is to send an update record that removes the diagnosis or diagnoses where ORM has ended. In this situation a TPOC date is not submitted, rather this is only submitted when ORM is completely terminated for all diagnoses.

The purpose behind these new policies is to improve coordination of benefits such that a Medicare beneficiary’s medical care is not denied when unrelated to a claim and prevent the recovery contractors from attempting to seek reimbursement for Medicare payments unrelated to a claim.

While we thank CMS and the BCRC for identifying solutions to the above reporting problems, we believe RREs may face some technical challenges in the ability to, for example, report two add records on the same claim.  We await issuance of the formal policy from CMS and will review how this policy change can best be incorporated into the Section 111 reporting process.

In addition to announcing the new reporting policy, CMS and the contractors provided the following advice:

Respond to correct contractor – Carefully review the correspondence and make sure to respond to the contractor that sent the letter, whether it’s to obtain further information, dispute/appeal charges, or to make payment.

As a reminder, CMS noted, the BCRC is generally recovering conditional payments when the identified debtor is the Medicare beneficiary while the CRC is recovering conditional payments when the insurer/WC carrier is the identified debtor.

CMS provided the following guidance regarding key timeframes:

  • Interest accrues from the date of the demand letter and is assessed on debt if not resolved within 60 days.
    • When CMS issues a demand letter directly to the applicable plan, the applicable plan has formal administrative appeal rights.
    • The applicable plan has 120 days from the date the applicable plan receives the demand letter to file a redetermination (first level of appeal). Interest will still accrue during this time.
    • If the appeal is not filed within 120 days, and “good cause” for untimely filing is not provided, the appeal will be dismissed.
    • Failure to resolve the debt will result in referral to treasury at 180 days.

Note:  When you are appealing to the ALJ please be sure to cc the CRC so that they can appropriately place a hold on a case so that it is not referred to treasury while the appeal is in process.

During the Q&A portion of the webinar CMS and its contractors addressed varied questions; some are summarized below:

  • What can be done if we cannot obtain a Social Security number from the claimant? CMS advised them to document their efforts at obtaining the SSN.  It was noted CMS has model language found on the CMS website which can be used to document claimant’s refusal to provide SSN.
  • In response to a question concerning the many charges found on conditional payment notices and demands that are unrelated to the injury, CMS/CRC acknowledged that it is not a perfect process. The CRC explained that when conditional payment information is requested what is sent to the requestor may have only been produced through an automated search of charges related to the injury.  CRC did advise that when it comes to actual issuance of a demand that there is a human validating process.
  • In response to a question concerning why in response to a dispute of a Conditional Payment Notice, one might receive another CPN with new charges, the CRC explained that this is the result of the system constantly reviewing for additional charges deemed related to the injury.
  • There were several questions regarding problems with the CRC recognizing out-of-pocket reimbursements to claimants in a no-fault/med-pay claim as counting towards the exhaustion of the no-fault maximum amount. CRC’s response was to advise entities to provide plan documents and proof of payment to the claimant along with a reason for the payment.  Its leader said, “We are aware that no-fault payors have run into problems with CRC rejecting out-of-pocket expenses as included within the no-fault exhaustion amount.”

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

Related prior posts:

CMS RELEASES TECHNICAL UPDATES TO SECTION 111 USER GUIDE

Tower MSA Partners Ready to Steer Clients Through Pending Section 111 Civil Money Penalties

April 1, 2021

View from Dashboard over highway to illustrate Section 111 Civil Money Post

Last year the Centers for Medicare and Medicaid Services (CMS) proposed regulations on Section 111 civil money penalties (CMPs). See Tower MSA Partners’ detailed prior post, CMS issues Proposed Rule for Mandatory Insurer Reporting Penalties related to inaccurate or untimely Section 111 Medicare Mandatory Insurer Reporting. Some of these are shocking – up to $1,000 per day per claimant in some cases.  Tower and others in the Medicare Secondary Payer (MSP) industry collaborated on comments to CMS’s proposal.

Then, Tower went well beyond simply responding to CMS.  We took proactive measures to prepare our clients for the eventual penalties. We educated clients with a webinar focused specifically on the subject matter, and we have communicated frequently.

Tower’s proprietary tech tools help prevent Section 111 Civil Money Penalties

In addition to education and communication, with Tower’s focus on technology to measure, manage and drive results, we built a dashboard to steer our clients through MSP compliance so they can avoid CMPs when they go into effect.  See our news release for details: Tower MSA Partners Releases Medicare Mandatory Reporting Dashboard.

Our S111 Management Dashboard gives you the 24/7 data and reporting oversight for every aspect /of the reporting process.  Workers’ compensation and liability payers usually have limited visibility into claims history through their Section 111 providers’ reporting systems.  They may receive compliance error reports but aren’t able to quickly verify compliance accuracy.  Few systems remind responsible reporting entities to update the ongoing responsibility for medicals (ORM) termination dates when claims are settled.

The dashboard gives clients full visibility into their claims from a global level all the way down into the details of a specific claim.  You can manage the accuracy of data, such as ICD 10 codes or ORM to avoid unnecessary conditional payment or MSA exposure in addition to avoiding CMPs.

“The dashboard is intuitive and simple to use,” said Todd Venneri, Business Intelligence Project Manager for BETA Healthcare Group, who tested its features. “The ability to quickly access and verify claim information is invaluable.”

While our intuitive S111 Management Dashboard was being developed, we also updated our client portal and MSP Automation Suite. Keep in mind, Tower’s system was built specifically by us for this industry.  It seamlessly manages Section 111 reporting, conditional payments, Medicare Set-Aside triage, clinical and legal interventions, MSA preparation, and CMS submission activities that take clients through settlement and closure.

We don’t know when CMPs will be announced or how Section 111 civil money penalties will be assessed.  What we do know, however, is that our clear, concise dashboard has replaced uncertainty with knowledge and information.

We are ready and we want you to be ready, too.  If you have not used the dashboard yet, take it for a spin.  Get in touch with Hany Abdelsayed at hany.abdelsayed@towermsa.com or 916-878-8062 for a demo.

CMS Releases Technical Updates to Section 111 User Guide

January 26, 2021

CMS User Guides for Section 111 Reporting. open book with colored page markers

The Centers for Medicare and Medicaid Services (CMS) has begun the new year with some updates to its MMSEA Section 111 NGHP User Guide.  This guide provides everything and anything you ever wanted to know about mandatory insurer reporting by non-group health plans.  Version 6.2 provides the following updates:
 
$750 Reporting Threshold
 
In follow-up to its November 2020 announcement that it will be maintaining the $750 TPOC threshold for reporting and Medicare conditional payment recovery, CMS states:
 
As of January 1, 2021, 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 (Sections 6.4.2, 6.4.3, and 6.4.4).
 
Key takeaway:  Maintaining the $750 threshold means there are no changes to the reporting processes, determinations of claims that should be reported, or when conditional payments should be investigated or resolved.
 
Reporting Future ORM Termination Date
 
Per CMS:
 
To address situations where Responsible Report Entities (RREs) can identify future ORM termination dates based on terms of the insurance contract, RREs can now enter a future Ongoing Responsibility for Medicals (ORM) Termination Date (Field 79) up to 75 years from the current date (Section 6.7.1)
 
Key takeaway:  A future ORM termination date can only be submitted if it is certain, e.g., the date is specified in an insurance contract or a statutory limitation provides for its exact determination. The prior policy only allowed the reporting of an ORM termination date that was six months into the future.  The expansion to 75 years should allow for most date certain ORM terminations to be reported.
 
Data Exchange Update
 
Per CMS:
 
As part of CMS’ commitment to the modernization of the Coordination of Benefits & Recovery (COB&R) operating environment, changes are being implemented to move certain electronic file transfer data exchanges to the CMS Enterprise File Transfer (EFT) protocol. As part of this change the exchange of data with the COB&R program via Connect:Direct to GHINY SNODE will be discontinued. The final cutover is targeted to occur in April 2021. File naming conventions and other references have been updated in this guide. Contact your EDI Representative for details (Sections 10.2 and 10.3).
 
Key takeaway:  Right now, CMS offers four methods of data transmission that Section 111 RREs or their reporting agents can use to submit and receive electronic files.  CMS is discontinuing the Connect:Direct method, and since Tower does not communicate with CMS via this method there will be no impact to our reporting processes.
 
Policy Number Now a Key Field
 
Per CMS:
 
To support previous system changes, Policy Number (Field 54) has been added as a key field. If this field changes, RREs must submit a delete Claim Input File record that matches the previously accepted add record, followed by a new add record with the changed information (i.e., delete/add process) (Sections 6.1.2, 6.6.1, 6.6.2, and 6.6.4).
 
Key takeaway:  Previously, if a claim input file was updated with a different policy number for the same claim it would create two records with the BCRC.  This could duplicate Medicare conditional payment recovery efforts.  CMS’s solution is to have the RRE delete the prior record with the old policy number and add a new record with the new policy number.
 
Retraction of Soft Code Error
 
Per CMS:
 
In Version 6.1, we announced that several input errors will become “soft” errors starting April 5, 2021. However, CP03 will not become a soft edit. The Office Code/Site ID (Field 53), which triggers CP03, is used to identify correspondence addresses, and if incorrect, could result in mail being sent to the wrong place. Therefore this error will continue to reject the record (Appendix F).
 
Key Takeaway:  An error in Office Code/Site ID (Field 53) will not be considered a soft edit and will result in file rejection. An earlier Tower article, November CMS Mandatory Reporting and Conditional Payment Updates, explained these so-called “soft” code errors.
 
If you have any questions on these updates to the Section 111 User Guide, please reach out to Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.
 

Three Medicare Secondary Payer (MSP) Predictions for 2021

January 14, 2021

rainbow over a highway with the year 2021 painted, illustrating predictions for Medicare Secondary Payer in 2021

We take a look at what’s in the crystal ball for Medicare Secondary Payer (MSP) short-term issues in the year ahead.

This year marks the 20th anniversary of the famous —or infamous, depending on your perspective— “Patel Memo” that formally launched CMS’s Workers’ Compensation Medicare Set-Aside review process.  It was probably safe to assume that a government program like this would still be around two decades later. However, the expansion of CMS’s authority to require mandatory reporting along with stepped up efforts to recover conditional payments by both Medicare and Medicare Advantage plans was less predictable.

I won’t hazard a guess on what Medicare Secondary Payer compliance will be like 20 years from now but will predict the outcomes of some short-term issues.

Liability MSAs

In June 2012 CMS issued an Advanced Notice of Proposed Rulemaking (ANPRM) with ideas as to how Medicare’s interests could be considered in the settlement of future medicals in a liability case.  Ultimately, the ANPRM was withdrawn in October 2014.

Nothing further was heard from CMS management until December 2018 when it indicated proposed rules would be issued in September 2019.  Subsequent notices postponed the date to March 2021.

Prediction:  Since CMS will have new leadership and its attention has turned to vaccine distribution, I suspect we will not see proposed rules on LMSAs this year.  Even if CMS proposes regulations, they would not be implemented until after a comment period followed by revisions, which would likely stretch into 2022.

Section 111 Penalties

On February 18, 2020, CMS issued its proposed regulations specifying how and when it would impose civil money penalties if Non-Group Health Plans fail to meet Section 111 Mandatory Insurer Reporting responsibilities.  A comment period ended on April 20, 2020 (Please see CMP Comments Submitted for Tower’s comments on the proposal).

Prediction:  Since CMS completed the process of releasing the proposed rule and receiving comment and the issuance of this regulation is statutorily required by the SMART Act of 2012 prior to issuing any penalties, I expect the final rule will be issued in 2021.  Once issued, it will likely become effective within 60 days.

PAID Act

On December 11, 2020, President Trump signed into law HR 8900, Further Continuing Appropriations Act, 2021, which included the provisions of the Provide Accurate Information Directly Act or PAID Act.

The PAID Act requires CMS to provide applicable plans (liability insurance, no-fault insurance and workers’ compensation laws or plans) access to Medicare beneficiary enrollment status in Medicare Advantage and Part D Prescription Drug plans through the Section 111 Mandatory Insurer Reporting process. (Please review PAID Act Becomes Law for a full explanation of the law and its implications.)

Prediction:  Per the law, CMS must provide access to Medicare Advantage and Part D plan information by December 11, 2021 (one year from the date of enactment).  As CMS must implement technical changes to the Section 111 reporting platform to provide such access, it may not be ready by that date.

Beyond these three predictions, some issues to watch in the coming year: 

  • Continued trend toward non-submit MSAs
  • More professional administration of MSAs
  • Cases affecting Medicare Advantage plan recovery rights
  • Per proposal from President-elect Biden, lowering of Medicare eligibility age to 60
  • “New” MSA reform legislation

A happy and safe new year to you and your families.