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WCMSA Reporting and MSP Compliance for 2025: Premier Webinar

December 18, 2024

Topic: WCMSA Reporting & MSP Compliance for 2025
Date: Thursday, January 16
Time: 2 PM ET

Are you prepared for the upcoming changes in workers’ compensation settlements? Starting April 4, 2025, all settlements involving Medicare beneficiaries will require a WCMSA amount to be reported—even if it’s $0—through Section 111 reporting process.

Join Dan Anders, Tower’s Chief Compliance Officer, and Jesse Shade, Chief Technology Officer, for an engaging and insightful webinar designed to help you navigate these significant changes.

In this one hour session, you’ll learn:

The key criteria and timeline for WCMSA reporting.
How to handle the technical implementation and testing process.
What these changes mean for claims professionals, attorneys, and settling parties.
Insights into MSAs and Conditional Payments in 2025.
Updates on Medicare Secondary Payer compliance under the new administration.

Bring your questions! A live Q&A session will follow the presentation, and you can submit questions during registration.

Don’t Wait—Get a Head Start on 2025!

Click below to reserve your spot and get the insights you need to stay ahead.

[Register Now]

Get ready, get informed, and stay compliant—see you on January 16!

October CMS Updates: Section 111 Reporting User Guide and Civil Money Penalties Webinar Highlights

October 31, 2024

Section 111 Reporting User Guide and Civil Money Penalties Webinar Highlights

Stay up-to-date with the latest CMS developments! This month, we’re covering the release of the NGHP Section 111 Reporting User Guide Version 7.7, the annual update to the ICD exclusion list, and key insights from the CMS Section 111 Civil Money Penalties webinar.

NGHP User Guide Version 7.7 Released

On October 7, 2024, CMS published Version 7.7 of the NGHP (Non-Group Health Plan) Section 111 Reporting User Guide. Here are notable updates:

Reporting of Wrongful Death Claims

In Chapter III; Policy Guidance, Section 6.5.1.4, CMS provided the following clarification:

“Note: Settlements, judgments, awards, or other payments obtained entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment.”

This statement is consistent with CMS’s previous guidance that Total Payment Obligation to Claimant (TPOC) amounts are reported only when medicals are claimed and/or released, or the settlement has the effect of releasing medicals.

Compliance Flags are now Warning Flags

In Chapter IV: Technical Information, CMS has renamed “Compliance Flags” in Section 7.4 to “Warning Flags.” Additionally, a new “04” warning flag has been introduced. This flag applies to claim response files with open Ongoing Responsibility for Medicals (ORM) records when the later date of either the CMS Date of Incident or the Part A Add Date is more than 135 calendar days after the Start Date of the Responsible Reporting Entity’s (RRE’s) submission period.

Understanding Warning Flags and Penalties

It’s important to note that warning flags do not necessarily equate to a potential civil monetary penalty for late Section 111 reporting. Here’s the key difference:

Warning Flags: Triggered if ORM or TPOC is reported more than 135 days after it should have been reported, as defined in the user guide.
Penalties: Potential penalties don’t come into play until 365 days have passed since the date the information should have been reported.

Why the different timeframes? We assume it is to encourage RREs to report promptly, ensuring CMS has the necessary information to coordinate benefits properly. Warning flags act as a reminder to the RRE that repeated reporting delays could lead to more significant issues, including potential penalties.

Updated ICD Code Excluded List

CMS published its annual update of valid and excluded liability and no-fault ICD-9 and ICD-10 codes for Section 111 reporting purposes. The list can be found here.

CMS Webinar Highlights: Section 111 Civil Money Penalties

On October 17, 2024, CMS hosted a webinar on Section 111 Civil Money Penalties. The webinar slides can be found here. Key takeaways:

Civil Money Penalty Correspondence: Notices will be mailed to the RRE’s Authorized Representative and the Account Manager. Reporting agents, such as Tower MSA Partners, will not receive a copy of the notice. Therefore, it is important for the RRE to ensure address information is up-to-date.

Compliance Clock Started: The compliance clock began ticking on October 11, 2024. Eligible MSP occurrences occurring on or after this date must be reported within 365 days.

Obtaining Beneficiary Information: When trying to gather beneficiary details, such as a Social Security Number, the RRE must reach out to both the beneficiary and, if applicable, their attorney. Contacting only the attorney isn’t sufficient. Additionally, you must make at least three attempts to obtain the information, with at least two attempts made via mail or email.

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

Significant Changes Coming to Florida Fee Schedule: What It Means for Your MSA Costs

October 24, 2024

Florida’s 2025 Fee Schedule Changes Will Raise MSA Costs

Starting January 1, 2025, Florida is making some significant changes to its fee schedule, which will lead to higher MSA (Medicare Set-Aside) costs – sometimes significantly so. Here’s what you need to know.

Increased Physician Reimbursement Rates in Florida’s New Fee Schedule

In June 2024, the governor signed a new law that increases the maximum reimbursement rates for physicians and surgical procedures. For doctors, the rates will jump from 110% to 175% of the Medicare allowable reimbursement rate, while surgical procedures rates will rise from 140% to 210%. The Florida Association of Orthopaedic Executives said “that represents an unprecedented increase in physician reimbursement of 59% for non-surgical codes and 50% for surgical care.” These rates haven’t changed in 20 years, and Florida is presently the lowest in the nation.

How Florida’s New Fee Schedule Affects MSA Pricing

What does this mean for MSAs? Since MSA pricing is based on the relevant workers’ compensation fee schedule, there is an opportunity to lock in lower costs for Florida MSAs if you get CMS approval before January 1, 2025.

What Should You Do?

Already Have an MSA Prepared? If Tower has already prepared a Florida MSA for you and the estimated settlement exceeds CMS MSA review thresholds, submit it as soon as possible to achieve cost-savings.
No MSA Yet, But Settlement Coming Soon? If you’re expecting a settlement in the coming months, now is the time to get an MSA prepared and submitted for approval.

Remember, once CMS approves an MSA, that approval does not expire. So, even if settlement occurs after the fee changes, the approved MSA amount remains valid.

If you have any questions, feel free to reach out to Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com. And, if you’re ready to move forward with a Florida MSA submission or preparation, please contact us at referrals@towermsa.com.

CMS Sets October 17 for Webinar on Section 111 Reporting Penalties

October 9, 2024

Upcoming CMS Webinar on Section 111 Reporting Penalties

The Centers for Medicare and Medicaid Services (CMS) has scheduled an important webinar on October 17, 2024, at 1:00 PM ET, specifically covering Section 111 reporting Civil Money Penalties (CMPs) and their implications for all relevant stakeholders involved in compliance and reporting.

Webinar Format and Focus From CMS

CMS will be hosting a comprehensive webinar regarding Certain Civil Money Penalties for NGHP Responsible Reporting Entities (RREs). This informative session aims to clarify the implications of these penalties and ensure that all RREs are well-informed. The format will include opening remarks from CMS officials, followed by a detailed presentation that will cover essential topics. Attendees can expect reminders about the Final Rule, insights into the auditing process, and critical dates that RREs need to remember. After the presentation, there will be a dedicated question-and-answer session, allowing participants to seek clarification and address specific concerns related to the Civil Money Penalties. This interactive component is designed to enhance understanding and foster engagement among all attendees.

RREs who would like to submit questions in advance of the webinar are encouraged to do so using the dedicated resource mailbox at Sec111CMP@cms.hhs.gov.

There is no pre-registration for the webinar. Full details can be found here.

Previous Webinar Insights

The upcoming webinar focuses on Section 111 penalties, while a previous webinar covered Section 111 reporting best practices and upcoming changes. A copy of the slides and notes of the prior session are here.

CMS recently added a new page to its website, which provides NGHP Civil Money Penalties information, including a flow chart. CMPs are applicable starting October 11, 2024, and audits begin in January 2026. We encourage a review of CMS’ website and articles Tower has published on the topic, including Section 111 Reporting for WCMSAs & Avoiding Civil Penalties.

Tower Premier Webinar: A Claims Professional’s Guide to Successful Settlements with MSAs

September 12, 2024

Overcoming Medicare Set-Asides Challenges: Key Strategies for Successful Settlements

Navigating Medicare Set-Asides can often feel like a daunting challenge during settlement. Even when all parties agree on the need to include an MSA, the allocation may be too high or the documentation requirements too burdensome.
However, the MSA hurdle can be overcome with the right approach.

Understanding when an MSA is appropriate, what’s needed to prepare a reasonable MSA, and how to manage cost and time factors are key to overcoming these obstacles.

Join Our Webinar: Expert Guide to MSAs on October 2, 2024

Join us on October 2, 2024, at 2 pm ET, as Tower’s Chief Compliance Officer, Dan Anders, and Brittney O’Neal, Director of Clinical Operations, present a claims professional’s guide to successful settlements with MSAs. In this webinar, we’ll cover:

• The appropriate time to obtain an MSA
• Essential documentation for drafting an MSA
• Differentiating between Medicare-covered or non-Medicare-covered treatment
• Understanding the difference between submitted and non-submitted MSAs
• Strategies when a CMS-approved MSA cannot be obtained
• Utilizing the CMS re-review and amended review process effectively
• Circumstances when a $0 MSA is appropriate
• The value of MSA professional administration and structured settlements

If you are interested in the ins and outs of MSAs, this free webinar is for you. Plus, if there is something about MSAs you’ve always wondered about, ask us! When you click on the registration link below, you will not only be able to register, but you can also submit a question to be answered during the webinar.

Hope you can join us on October 2 at 2 pm ET!

Tower-sponsored WCI-TV Segments Focus on Empathy

August 14, 2024

Empathy. We know we need it, but what exactly is it and how do we use it to help injured employees?

The Miriam-Webster dictionary defines empathy as the “action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts and experience of another.” The Society for General Internal Medicine tweaked the definition to apply to healthcare as “the act of correctly acknowledging the emotional state of another without experiencing that state oneself.”

Empathy: A Key to Enhancing Worker Satisfaction and Streamlining Claims in Workers’ Compensation

The workers’ compensation community has embraced the concept of empathy. In articles and at conferences, experts say that injured employees who receive empathy from their providers, employers and insurers report higher levels of satisfaction with their care and are less likely to hire attorneys. It makes sense that an injured worker who feels heard and understood will be more apt to participate in their care, recover faster and return to work. Settlement professionals, like our partner Ametros, have seen empathetic communication break down barriers to the settlement of claims.

So how does one acknowledge the emotional state of another? What does empathy look like in the real world? Is it a skill that can be taught? Can you be too empathetic? Are there ways to incorporate empathy into claims management processes?

Tower will explore these questions during our sponsored WCI-TV interviews. Our guests include Joan Vincenz, Managing Director, Corporate Safety for United Airlines and Greg Hamlin, Senior Vice President and Chief Claims Officer of Berkley Industrial Comp. Other interviews feature Kristi Montoya, Director of Claims Operations for UPS, and Denise Evans, the Director of Claims for Staffmark. Our Chief Compliance Officer Dan Anders and our Chief Operating Officer Kristine Dudley will also share their views.

Tower is the founding sponsor of WCI-TV, which airs during the WCI conference, in hotel rooms and on shuttles as well as on You Tube and WCI’s website. You can see the interviews on Tower’s Linked In home page, too. The 78^th Annual WCI Conference will be held August 18-21 at the Orlando World Center Marriott.

While at WCI, Dan Anders will also moderate a Medicare Secondary Payer Compliance Panel. The “Pre-Settlement Considerations” session runs from 2-3 p.m. on Tuesday, August 20 and features Ametros’ John Kane, Brian Broznowicz with the Centers for Medicare and Medicaid Services, Ringler’s Jarrod Zea, and Kristi Montoya with UPS.

WCI is always busy, but we’d love to catch up with you there! Dan, Kristine Dudley and Hany Abdelsayed will attend the conference. To schedule a meeting before WCI, email daniel.anders@towermsa.com. Otherwise, grab us in the hallways or at the WCI-TV studio.

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.

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.

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.