Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards, or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation.

Non-Group Health Plan reporting entities have been waiting for over a decade for clarification on when and how civil monetary penalties (CMPs) for non-compliance with the Section 111 reporting guidelines will be assessed. The proposed rule that will specify how and when CMS must calculate and impose CMPs was published on February 18, 2020.

On February 17, 2023, CMS announced that they will be extending the time for publication of the final rule until February 18, 2024. In sum, it was noted that additional data analysis and predictive modeling need to be done to better understand the economic impact of the rule on different insurer types. The official announcement for the delay will be published in the Federal Registrar on February 22, 2023.

And according to an article on this topic written by attorney and former nurse Ciara Koba, one of the nation’s foremost authorities on Medicare Mandatory Insurer Reporting, this undoubtedly allowed Responsible Reporting Entities (RREs) to take a breath and focus on continuing to improve and streamline processes to ensure they are compliant.

She said that “It was a relief that there has been an acknowledgement of how grave the potential economic impact could be if the max penalties were to be imposed.”

For illustrative purposes, she pointed out that “if an RRE failed to report 100 claims for a period of 90 days. The proposed penalty could reach a staggering $9,000,000 without even accounting for the inflationary daily penalty which would be closer to $1,200 per day per claim.”

With this new timeframe in mind, she went on to say that it is important for responsible reporting entities to pay close attention to any guidance that CMS distributes and take this extra year to implement any necessary improvements to Section 111 reporting systems and processes. On December 6, 2022, CMS presented a webinar on Section 111 reminders and best practice, additional resources and allowed for an open question and answer session.

CMS uses the term TPOC to refer to the dollar amount of the total payment obligation to, or on behalf of, the injured party in connection with the settlement, judgment, award, or other payment in addition to/apart from Ongoing Responsibility for Medicals (ORM). CMS stressed that accurate Section 111 reporting of TPOCs and ORM assists CMS and their contractors with accurate recovery.

CMS discussed how to calculate the TPOC and what is included with specific focus on the fact that indemnity only settlements do not get reported. Logically, this makes sense because the injured Medicare beneficiary is not being compensated for medical damages, and as such, the indemnity only settlement is not reportable because CMS cannot assert a recovery claim for conditional payments against an indemnity only settlement.

CMS also discussed the Event Table contained in Section 6.6.4 of Chapter 4 of the NGHP User Guide for Section 111 reporting. This Event Table can be useful to reporting entities when trying to determine when, what and how to report a particular beneficiary and their claim data. It covers a wide array of event scenarios and CMS reviewed two common issues and reviewed the appropriate action per the User Guide. The second scenario CMS reviewed is as follows:

ORM ends for one body part due to TPOC, but ORM continues for another body part for the same claim. The recommended action for this scenario is to send an update record for the open ORM report (Action Type 2) and remove the diagnoses codes for the body parts that have settled. Then the reporting entity should send an Add record to report the TPOC for the body part that settled.

The solution proposed by CMS is logical if you are working in a system where this is something that is possible. For example, what if the RRE has their TPA reporting their claims for them and the only way to submit an “Add” record in this scenario is to open a new claim for which the RRE will be charged a fee by the TPA.

There are a lot of RREs that are unable to open multiple claims in their systems when all of the action for the claim is really under one claim/policy number in their system. As such, The Medicare Secondary Payer Network (MSPN) has been discussing possible solutions to this issue that will allow CMS to obtain the information that they need for recovery efforts and that will allow the RREs to do the reporting accurately without having to open additional claims to report multiple TPOCs and/or ORM timeframes for different body parts/injuries.

CMS also released the top 10 error codes that they have received from July 1, 2022 through October 7, 2022. This data was very interesting, and RREs should pay particularly close attention to this data.

If you would like to analyze your data but don’t know where to start, please reach out to Ciara Koba at info@allankoba.com.