Category: Section 111 Reporting

CMS Releases Updated Section 111 and MSPRP User Guides – Schedules Reporting Webinar

July 17, 2020

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

New CMS User Guides released.

The Centers for Medicare and Medicaid Services (CMS) recently released updated user guides for Non-Group Health Plan MMSEA Section 111 Mandatory Insurer Reporting and the Medicare Secondary Payer Recovery Portal (MSPRP).  CMS also just announced an August webinar on Section 111 reporting matters.

CMS User Guides: Updated MMSEA Section 111

On June 29, CMS released Version 5.9 of the NGHP MMSEA Section 111 User Guide.  Highlights of the updated user guide:

  • A reminder has been added that while the threshold for physical trauma-based liability insurance settlements remains at $750, this threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases. (Sections 6.4.2, 6.4.3, and 6.4.4).
  • The limit dollar amount that triggers a threshold error has been adjusted from $99,999,999 to $99,999,999.99. This error occurs any time the No-Fault Insurance Limit amount or the cumulative value of all reported TPOCs (detailed and auxiliary records) exceed this limit. Additionally, the No-Fault Insurance Limit field number has been corrected under “Exceptions.” (Section 7.3.2).
  • When considering the requirements for the Ongoing Responsibility for Medicals (ORM), remember, per current policy, that the dollar limit for No-Fault Insurance Limits (Field 61) represents a combined total of Med-Pay and Personal Injury Protection (PIP) (Section 6.7.1).
  • When considering the requirements for the Ongoing Responsibility for Medicals (ORM), remember, per current policy, that the dollar limit for No-Fault Insurance Limits (Field 61) represents a combined total of Med-Pay and Personal Injury Protection (PIP) (Appendix A).
  • The CR02 claim response file error code field number has been corrected (Appendix F) (Table F-4).

CMS User Guides: Updated MSPRP

On July 13, CMS released Version 4.9 of its MSPRP User Guide.  The MSPRP is a web-based application which allows authorized users to, among other tasks, investigate, dispute and resolve Medicare conditional payments.  Updates can be found on page 1-1 of the user guide.  Significantly, users can now view and print outgoing correspondence from the MSPRP.  This is correspondence that has been received or letters that have been sent related to a BCRC or CRC case.

Section 111 Reporting Webinar

CMS will be hosting a Section 111 NGHP webinar on August 13, 2020 at 1:00 PM ET.  According to the notice, “the format will be opening remarks by CMS followed by a presentation that will include NGHP reporting best practices and reminders.”  The webinar notice can be found here.

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

CMS Provides Notices on Section 111 Reporting and Conditional Payment Processes

June 17, 2020

People using laptop and mobile phones to update Section 111 Reporting

CMS has recently issued two notices, one pertaining to mandatory Section 111 reporting and one relevant to Medicare conditional payment recovery.

First, in a “teaser” notice, CMS announced that on July 13, 2020 the Medicare Secondary Payer Recovery Portal (MSPRP) is scheduled to be enhanced to allow authorized users to view and print correspondence.

According to the notice,

MSPRP users who log in using Multi Factor Authentication will be able to view and print CMS mailed correspondence that is displayed on the Letter Activity tab. Additional information on how to use this new functionality will be available in Section 14.1.1.4 of the July version of the MSPRP User Guide.

Second, in an alert entitled “Reporting No-Fault Insurance Limit on Non-Group Health Plan (NGHP) Claim Input Files,” CMS reminds Responsible Reporting Entities (RREs) that they must combine both Med Pay and Personal Injury Protection (PIP) coverage limits for Section 111 reporting purposes.  This would be under circumstances where separate Med Pay and PIP coverages are being paid out on claims for the same injured party and incident under a single policy.

CMS also reminded RREs that ORM cannot be terminated until both Med Pay and PIP coverage limits are exhausted.  Further, that when providing the dollar amount for the policy limit, that it must accurately reflect two decimal places.  For example, a policy limits of $5,000 should be reported as 500000.

Practical Implications

In regard to the MSPRP enhancement to print documents, while we will have to see the specific guidance in the July update, this may prove quite useful in not having to wait for correspondence to come in the mail, print letters that were not received via the mail or reprint letters.

As for the alert to remind No-Fault carriers to report Med Pay and PIP coverage limits as a combined amount, while this guidance is already included in the NGHP User Guide, there was apparently some confusion that led CMS to provide this alert as a reminder of how such coverage must be reported.

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

Proposed Rules on LMSAs and Section 111 Penalties Again Delayed

November 25, 2019

US Capitol dome

Almost a year ago the U.S. Office of Management and Budget posted two rulemaking notices from the Centers for Medicare and Medicaid Services (CMS) entitled Civil Money Penalties and Medicare Secondary Payer Reporting Requirements and Miscellaneous Medicare Secondary Payer Clarifications and Updates.  Per our understanding, the purpose of this rulemaking is to provide proposals for how and when penalties will be imposed in Section 111 Mandatory Insurer Reporting and for a Liability Medicare Set-Aside review process.

When issued in December 2018, both notices indicated the proposed rules would be issued in September 2019.  Subsequent notices moved the date to October 2019 and we now have notices moving the date for issuing the proposed rule on penalties to December 2019 and for rules on LMSAs to February 2020.

Practical Implications

The lesson here is these are not hard and fast dates as they have already been moved twice and we assume may be moved again.  At some point we expect the proposed rules to be issued which will be followed by comment periods (likely a 60-day period each).  CMS will take public comments under review and then issue final rules with effective dates.  As such, we are looking at a rulemaking process that will stretch well into 2020 and possibly into 2021.

For more background on these rules please read our prior article, CMS Rulemaking Notices Provide Possible Timeline on LMSAs and Reporting Penalties.

If you have any questions, please contact Dan Anders at (888) 331.4941 or daniel.anders@towermsa.com.

Updated Section 111 User Guide Provides for Transition to MBIs, ORM Termination Defined

January 3, 2018

Pursuant to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, CMS is required to transition all Medicare beneficiaries from the Social Security Number based Health Insurance Claim Numbers (HICNs) to a new identification number called a Medicare Beneficiary Identifier (MBI). The primary purpose of this initiative is to reduce identify theft associated with use of Social Security Numbers in HICNs.

Accordingly, starting in April 2018 CMS will begin to mail new cards with the new Medicare numbers to Medicare beneficiaries. The goal is to issue all new cards by April 2019. For medical providers, there will be a transition period from 4/1/2018 through 12/31/2019 in which either the HICN or MBI will be accepted for processing of payments by Medicare.

Minimal Impact on Section 111 Reporting

Unlike medical providers which must exclusively use the MBI by 1/1/2020, as explained in the updated Section 111 NGHP User Guide, CMS has exempted its Medicare Secondary Payer Reporting processes from exclusive use of the MBI. Consequently, we can continue to report to CMS using a Social Security Number, a HICN or an MBI. In announcing this policy, CMS indicates it has renamed fields labeled “HICN” to “Medicare ID.”

While allowing for continued reporting of HICNs in its Section 111 reporting processes, CMS states that if an MBI has been issued to the claimant, it will return the MBI in the Section 111 response files. We expect then that while not requiring submission of MBIs, CMS nonetheless expects a natural transition to their use for MSP matters over time.

Medicare Conditional Payment Recovery Correspondence to Include Either HICN or MBI

As part of this update, CMS states that its recovery contractors, the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC), will use either an HICN or MBI in its correspondence based upon the most recent information provided by the Responsible Reporting Entity (RRE) when creating or updating the MSP record. Again, we expect a natural transition from use of HICNs to MBIs in correspondence from the recovery contractors over the next few years.

The Tower MSP Automation Suite is fully capable of accepting SSNs, HICNs or MBIs for purposes of Section 111 Mandatory Insurer Reporting.

ORM Termination Defined

In addition to updating its User Guide to address the transition to MBIs, CMS also added language to its Section 111 “Policy Guidance” User Guide specifically defining under what circumstances Ongoing Responsibility for Medical (ORM) may be terminated. The revised Section 6.3.2 states as follows:

6.3.2 ORM Termination

When ORM ends, the RRE should report the date that ORM terminated and should NOT delete the record. Please note that a TPOC amount is not required to report an ORM termination date. An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:

  • Where there is no practical likelihood of associated future medical treatment, an RREs may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
  • Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;
  • Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.

While now formalized, this ORM termination guidance had previously been provided by CMS, either in other sections of the User Guide or in guidance provided outside the guide, such as through CMS Townhall calls.

Notably, advocacy efforts have been made with CMS to request an expansion of the ORM termination criteria. Such expansion would, for example, provide for ORM termination if no medical has been paid on a claim over a certain number of years. The benefit of allowing for a greater number of claims to terminate ORM would be less of an administrative burden for employers and carriers and a reduction in denials of payment by Medicare for charges completely unrelated to reported claims.

Unfortunately, CMS has thus far been unresponsive to expanding its definition of ORM termination, choosing instead to work out improper denial of payments and unwarranted conditional payment recovery efforts on the back-end rather than addressing the quality of the data reported to CMS on the front-end.

The Updated Section 111 User Guide, Version 5.3, may be found here.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding the updated guide.

Accuracy in Section 111 Reporting of ORM Vital to Avoiding Unnecessary Repayment Demands from Medicare

July 24, 2017

While the Commercial Repayment Center (CRC) has faced some valid criticism over the course of the past year and half in relation to its recovery efforts on behalf of the Centers for Medicare and Medicaid Services’ (CMS), not all problems start with the CRC. CRC’s recovery efforts are driven by the data employers, carriers and self-insured entities report to Medicare through the Section 111 Mandatory Insurer Reporting process. Chief among the data elements reported is acceptance of Ongoing Responsibility for Medicals (ORM) and the termination thereof. If this data is reported inaccurately or there is a failure to report required data, then the applicable plan may be faced with inappropriate recovery demands by the CRC.

Applicable Plan Reporting of ORM is the Catalyst for CRC Recovery Efforts

Since October 5, 2015, the CRC has had responsibility for the recovery of conditional payments where the insurer or employer (including self-insured entities) is the identified debtor, known in CMS terms as the “applicable plan.” The CRC learns of opportunities to recover through the Section 111 Mandatory Insurer Reporting process. In other words, the applicable plan is the catalyst for Medicare conditional payment recovery by its reporting of ORM.

The mandatory reporting provisions of the Medicare Secondary Payer Act require the applicable plan to report to Medicare in three instances – the acceptance of ORM, the termination of ORM and issuance of a Total Payment Obligation to the Claimant (TPOC), settlement judgment, award or other payment. In regard to ORM, two key data elements reported are the date responsibility for ORM is accepted and the accepted diagnosis codes. Once this information is reported the following actions are initiated by CMS’s contractors:

1. The BCRC, which handles Medicare coordination of benefits, should deny payment for medical bills submitted for payment in which the billed diagnosis codes match or is similar to the reported diagnosis codes.

2. The CRC identifies medical claims that Medicare has paid that it deems related to the reported diagnosis codes.

Upon the CRC identifying treatment related to the reported diagnosis codes, it will issue a Conditional Payment Notice (CPN) to the applicable plan which itemizes charges deemed related to the injury. The applicable plan has 30 days from the date on the CPN to dispute charges after which a Demand Letter will issue demanding repayment for the charges identified by the CRC. A Demand Letter provides 120 days from receipt of the letter for the applicable plan to appeal all or some of the charges or issue payment. If payment is not issued within 60 days of receipt, interest begins to accrue from the Demand Letter date.

Reporting Accurate Acceptance of ORM and Diagnosis Codes

The trigger for reporting ORM is a claimant identified as a Medicare beneficiary and the assumption of ORM by the applicable plan. ORM is reported when the applicable plan has made a determination to assume responsibility for ORM, or is otherwise required to assume ORM—not when (or after) the first payment for medicals under ORM has actually been made. Accordingly, the ORM acceptance date is typically the date of injury.

Along with the ORM acceptance date, at least one ICD-10 diagnosis code must be reported for the diagnosis that has been accepted on the claim (If more than one diagnosis has been accepted, then additional diagnosis codes are reported). While medical provider billing records are often used to determine ICD-10 diagnosis codes to report, these should be used as a starting point, not an ending point, in identifying the correct codes to report to Medicare.

Keep in mind that medical providers, and especially hospitals, will often insert into billing records any diagnosis reported to the provider, which are not necessarily the same diagnoses that are being accepted on the claim. Consequently, the person responsible for determining the correct ICD-10 diagnosis code to report, usually the claims handler, must make an independent determination, separate and apart from the medical provider, as to whether the particular diagnosis is being accepted on the claim. If the billing records do not properly represent what is being accepted, or if further diagnosis codes are required to better define what is accepted, then online ICD-10 resources are available to identify codes which correctly represent the accepted body parts and conditions.

Once ORM and the diagnosis codes are reported, ORM is generally not addressed again until the date of ORM termination. However, causally related diagnoses may change over time, either expanding or retracting depending upon the circumstances in the claim. Accordingly, it is important to update the reported ICD-10 codes as necessary over the course of the claim.

ORM Termination Key to Cutting Off Liability to Medicare

Once ORM is accepted, CMS claims the right to recover against the applicable plan through the date of ORM termination. As such, recovery efforts by the CRC may happen years after the ORM was first reported. Further, if there is failure by the applicable plan to terminate ORM when appropriate, then the plan may receive repayment demands from CRC for time periods in which it has no liability to pay for medical treatment. An applicable plan may terminate ORM through the Section 111 Reporting process under the following situations:

Settlement with a release of medicals

No fault policy limit reached

Complete denial of the claim

Statute of limitations has run or medical benefits have otherwise been exhausted pursuant to state law

Judicial determination after a hearing on the merits finding no liability

Statement from treating physician – signed statement from the injured individual’s treating physician that he/she will require no further medical items or services associated with the claim/claimed injuries.

Keep in mind that closing a claim file is not a trigger for ORM termination unless it is accompanied by one of the above situations.

Providing CMS with an ORM termination gives a bookend to recovery by the CRC. If no termination date is provided, then CRC assumes the applicable plan remains liable for injury-related payments.

Recommendations for Ensuring Accurate ORM Reporting

The reporting of ORM acceptance and termination and defining accepted diagnosis codes is so important because it is the applicable plan’s admission of responsibility to pay for medical care during the reported time period and for the reported diagnoses. If an error is made in reporting or there is an omission in reporting, then it can result in attempts by Medicare to recover for conditional payments unrelated to the injury or for time periods during which the applicable plan is not liable. Errors in reporting can also lead to inappropriate denials in the payment of claimant’s medical care by Medicare or Medicare paying for medical care for which the applicable plan is responsible.

Recommendations to avoid these errors and omissions:

1. Train Claims Handlers on ORM Reporting: If a claims handler is responsible for inserting the data required for ORM reporting, then they require training as to when ORM acceptance and termination is to be reported and how to determine the appropriate diagnosis codes to report with ORM acceptance.

2. Effective Quality Assurance of ORM Reporting: Even with training, errors will occur. Additional resources placed into quality assurance of ORM reporting, such as double-checking claims for proper ORM termination and appropriate diagnosis code choices avoids the expenditure of additional resources at a later date to correct errors in reporting and correction of unnecessary recovery demands from the CRC. If you are an employer or carrier relying upon a TPA to report, it is especially recommended that a QA process be in place to check the data entered by the TPA.

3. Ensure Reporting Platform is Accurately Reporting: Section 111 Reporting is electronically based and requires a data exchange with Medicare. Errors can and will occur in this data exchange. Ensure you have a trusted and reliable reporting agent to assist with accurate reporting to Medicare.

Finally, if any correspondence is received from the CRC or the U.S. Treasury Department claiming conditional payment recovery it must be acted upon immediately. Do not assume the letter was issued in error and will simply go away. If you do not believe you are liable for the conditional payments for which the CRC is claiming recovery, first confirm you have correctly reported ORM and then work with your MSP compliance partner to appropriately dispute the charges.

For questions stemming from this article please contact Dan Anders at (888) 331-4941 Daniel.anders@towermsa.com.