Section 111 Reporting Archives

Tower MSA Partners’ Chief Compliance Officer Dan Anders Featured on Ametros Podcast “It’s Settled”

September 25, 2024

Dan Anders, Chief Compliance Officer at Tower MSA Partners, was recently featured on Ametros’ podcast, “It’s Settled.

We are excited to share that Dan Anders, Chief Compliance Officer at Tower MSA Partners, was recently featured on Ametros’ podcast, “It’s Settled.” In this engaging episode, Dan sat down with Andrea Mills, Ametros’ Chief Client Officer, and John Kane, Senior Vice President of Strategy, to dive deep into the latest news and developments surrounding Medicare Set-Asides (MSAs). This discussion covered essential topics that impact the workers’ compensation and liability settlement space, including upcoming changes to Section 111 reporting, best practices for preparing MSAs, and the value of professional administration.

Upcoming Section 111 Reporting Changes

One of the key topics covered was the upcoming changes to Section 111 reporting and their implications for insurers and self-insured entities. Dan provided insightful commentary on what these changes mean and how they will affect the reporting process. With new compliance requirements on the horizon, now is the time for stakeholders to review their reporting strategies and ensure they are prepared for these regulatory shifts.

When to Prepare an MSA

Another critical topic discussed was when to prepare an MSA. Dan highlighted the importance of evaluating the need for an MSA early in the settlement process to avoid costly delays. He also provided insights into how Tower MSA Partners helps clients navigate complex cases by offering expert guidance on when and how to prepare MSAs effectively.

The Value of Professional Administration

The conversation also touched on the value of professional administration for MSAs, emphasizing how Ametros helps individuals manage their settlement funds to ensure compliance with Medicare’s requirements. Dan, Andrea, and John discussed how professional administration not only ensures the longevity of settlement funds but also helps alleviate the administrative burden on injured individuals.

Tips for Preparing an MSA

During the episode, Dan shared several tips and tricks for preparing an MSA, helping listeners understand the importance of accuracy and thoroughness when it comes to documentation. He also explained how Tower MSA Partners’ streamlined approach helps clients minimize risks and expedite settlements.

Upcoming Webinars and Conferences

As the discussion wrapped up, the group previewed upcoming educational opportunities, including a webinar, A Claims Professional’s Guide to Successful Settlements with MSAs, hosted by Tower MSA Partners on October 2^nd. Dan encouraged attendees to sign up for this and other webinars to stay informed on compliance topics and best practices in the MSA industry.

Listen Now

You can catch this insightful episode of “It’s Settled” featuring Dan Anders by clicking here.

Stay tuned for more updates from Tower MSA Partners as we continue to provide our clients with the latest compliance and settlement strategies. Be sure to sign up for our upcoming October 2nd webinar to stay informed on these important issues.

CMS Sets September 12 for Webinar on Section 111 Reporting

August 28, 2024

Webinar on Section 111 Reporting of WCMSAs

Don’t Miss the CMS Webinar on Section 111 Reporting

The Centers for Medicare and Medicaid Services has scheduled a September 12, 2024 webinar on Section 111 reporting. Per the announcement:

The format will be opening remarks by CMS, a presentation that will include NGHP reporting best practices and reminders, followed by a question and answer session. For questions regarding Section 111 reporting, prior to the webinar, please utilize the Section 111 Resource Mailbox PL110-173SEC111-comments@cms.hhs.gov.

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

While CMS does not indicate the webinar is specific to Section 111 Civil Money Penalties, given that CMPs become applicable as of October 11, 2024, this presents an opportunity to have any questions addressed before that date. Questions around the April 4, 2025 implementation of Section 111 Reporting of WCMSAs would also be encouraged.

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.

Section 111 Mandatory Insurer Reporting Updates

February 22, 2024

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

Updated NGHP Section 111 User Guide

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

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

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

Top 10 List of Section 111 Reporting Errors

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

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

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

$750 Threshold Kept for Reporting and Conditional Payment Recovery

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

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

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