Section 111 Civil Monetary Penalty Rulemaking Update

On Friday, September 22nd, the White House Office of Management and Budget published a notice that provided that the review of the Medicare Secondary Payer Section 111 Reporting Civil Monetary Penalty Final Rule has been completed. As such, it is likely that the final rule will be published in the Federal Register very soon.
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New Maximum Settlement Amount for Fixed Percentage Demand Calculation Option

Commencing October 2, 2023, the new maximum settlement amount for the Fixed Percentage Option (FPO) will be $10,000. This is double the current maximum settlement amount for the FPO of $5,000. The function of a FPO in Medicare conditional payments cases is...
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CMS Releases Updated NGHP Section 111 User Guide, Version 7.3

CMS has continued the recent onslaught of Section 111 Reporting updates with the release of the latest iteration of the Non-Group Health Plan User Guide – Version 7.3. Given other recent updates, alerts, and townhall conferences held, this does not come as a surprise. Version 7.3 contains three main revisions...
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Section 111 Mandatory Insurer Reporting Update: Top 10 Errors and Empty NGHP Unsolicited Response Files

CMS has released an updated list of the Top 10 Section 111 NGHP Reporting error codes based on data from January to June 2023. Noteworthy errors include invalid Termination Date and Invalid Diagnosis Code 1, impacting conditional payment recovery. The total number of errors increased compared to the previous period, and CMS clarified that opted-in RREs will receive blank response files if no data is available, as per a recent alert...
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MSP Manual Update Puts MSAs into Motion at Provider Level

A recent change to a Medicare Secondary Payer Manual brings Medicare Set-Asides into play for doctors and other medical service providers, who as of March 24 are obligated to direct bill those trusts. Just a year after Medicare’s Workers’ Compensation Medicare Set-Aside Reference Guide update strenuously emphasized the utility of MSAs in protecting Beneficiary entitlements post settlement, the Centers for Medicare and Medicaid Services now put MSA policy in motion with this recent directive. This change is consistent with Medicare’s WCMSA policy and previous guidance that allocations of future medical expenses should be properly funded and spent down in order to protect entitlements. Previous versions of this Manual illustrated primary insurance as opposed to secondary insurance, but made no specific reference to Medicare Set-Asides.
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MD Law Firm Settles with DOJ for Failure to Reimburse Conditional Payments

In a recent publication, the U.S. Attorney’s Office for the District of Maryland has confirmed that a Baltimore-based firm – Kandel & Associates, P.A. has entered into a settlement agreement to resolve alleged claims that the firm failed to reimburse Medicare for conditional payments made by CMS on behalf of firm clients. The claims against Kandel allege that over several years, the firm received settlement proceeds on behalf of its clients but neither the firm nor its clients reimbursed Medicare for conditional payments. The USAO has identified at least twelve Medicare liens that went unresolved.
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Practice Alert: CMS Address Change

Effective March 13, 2023, the Centers for Medicare and Medicaid Services has issued an announcement that the mailing address has changed for Medicare’s Commercial Repayment Center (CRC). The CRC handles all liens for cases wherein Medicare considers the insurer/employer to be the debtor.
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“Section 111 Civil Monetary Penalty Rulemaking is Delayed”

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 and can be reviewed here. On February 17, 2023, CMS announced that they will be extending the time for publication of the final rule. 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.
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Compliance Update: MMSEA Section 111 Reporting

CMS opened 2023 with a series of updates to the NGHP Section 111 User Guide.
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New Re-Review Guidelines added to the WCMSA Reference Guide Version 3.8

On November 14, 2022, CMS released version 3.8 of the WCMSA Reference Guide. If you attended The National Medicare Secondary Payer Network 2022 Annual Conference in September, you may have been anxiously anticipating the release of this updated guide with the hope that clarification on re-review requests would be provided as CMS agency officials discussed these changes would be coming soon. Christmas has come early as CMS has provided clarification on re-review requests and made some changes. Specifically, CMS has added a new category entitled "Submission Error". Submitters may not submit re-review requests where the documentation originally submitted contained errors that resulted in a discrepancy in pricing of no less than $2,500. This new category and specific guidelines surrounding the same can be found in Section 16.1 and 16.2 of the WCMSA Reference Guide.
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Medicare Recovery Efforts May Increase

As what remains of 2022 dwindles into a new year, trending on the Medicare Conditional Payment front garners attention from industry stakeholders. Mounting concerns surrounding Civil Monetary Penalties associated with Section 111 Medicare Mandatory Insurer reporting (rulemaking anticipated by or before February 2023) could increase vigilance and reporting efforts. Additionally, a recent OIG audit, which coupled with procurement for various contractor positions administering the Medicare Secondary Payer program, pose changes for the last quarter of 2022 and into 2023.
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CMS Alert! CMS to Host Workers' Compensation Medicare Set-Aside Webinar

CMS published an Alert indicating it will be hosting a webinar to discuss a variety of WCMSA topics, including a summary of what's new in Medicare set-asides, and addressing questions related to the inclusion of treatments, application of state rules, re-reviews/amended reviews and more.
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CMS Launches 'Go Paperless' Option for MSPRP Account Holders

CMS will now provide RREs, as well as their Recovery Agents, with the option to go paperless with respect to Medicare recovery correspondence. In an updated NGHP Section 111 User Guide release, version 6.7, CMS states that insurers and their recovery agents may elect to receive electronic correspondence so long as a Medicare Secondary Payer Portal (MSPRP) account has been set up.
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CMS Discredits Non-Submits in WCMSA Reference Guide Version 3.5

Whether or not to submit has through the years been touted as the main event at dozens of national conferences and seminars, promoting these sessions like MSP cage-match battles, pitting experts against one another in impassioned debate. Today Medicare put to rest more than a decade of MSP industry contention regarding whether Workers’ Compensation Medicare Set-Asides meeting Medicare’s published review thresholds must be reviewed and approved to establish validity and afford protection to Beneficiaries’ future Medicare entitlements. The decision is in and the answer is yes.
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2022: LMSA Pushed to February, $750 Threshold Remains

It’s beginning to look a lot like LMSA rules aren’t happening in 2021. So if this was your wish from Santa, you must be on The Naughty List. This week, the Office of Information and Regulatory Affairs (OIRA) updated the timeframe from October 2021 to February of 2022. And for all of the “Nice” primary payers, beneficiaries, attorneys and insurance professionals, CMS kept its $750 minimum recovery threshold in place for the coming year.
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Section 111 Reporting Update

Over recent weeks, CMS has posted a duo of alerts to the Non-Group Health Plan Mandatory Insurer Reporting landing page. While these alerts do not place any new obligations or requirements on Responsible Reporting Entities, they do provide some helpful reminders, coupled with a bit of guidance.
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PAID Updates Added to Companion Guide Version 5.7

CMS has published an updated Benefits Coordination & Recovery Center (BCRC) 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting Non-GHP Entities Version 5.7.
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More PAID Act Updates 9/9

On September 9, 2021, CMS will host its second informational webinar relative to the PAID Act. Per CMS’ Alert dated August 9, 2021, the webinar “will offer important PAID Act reminders and focus on the details of the upcoming testing period, which will begin on September 13, 2021.” As with the roll-out webinar of June 23, 2021, a live question and answer session with both CMS staff and the Benefits Coordination and Recovery Center (BCRC) will follow.
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Wait for it ... Again: LMSA Rules in October?

In yet another push into the future, the Office of Information and Regulatory Affairs (OIRA) Dashboard today indicates that any possible Notice of Proposed Rulemaking regarding Medicare Secondary Payer and Future Medicals (CMS-6047) will not occur until October of 2021, at the earliest.
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CMS UPDATE: New Section 111 User Guide Released with PAID Act Information

Two weeks in advance of its PAID Act webinar, CMS has released an updated NGHP Section 111 User Guide.  While the latest version contains several updates, the most intriguing and most impactful may be the announcement that the changes to the Medicare entitlement information provided via the Section 111 query process outlined by the PAID Act will be effective December 11 of this year.
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CMS to Debut PAID Act Details in Webinar on June 23rd

On June 23, 2021, Medicare will debut details relative to the PAID Act (Provide Accurate Information Directly), a new law designed to help Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) better coordinate benefits by providing them with Medicare Beneficiary Part C and Part D enrollment information.
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This is not a bill: NC District Court addresses ripeness...

Common Medicare Secondary Payer question: When is a Medicare Conditional Payment due?
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MSP Admissions Questionnaire and it's impact on the MSP system overall...

On September 15, 2020, the Centers for Medicare and Medicaid Services (CMS) published changes to the MSP Admissions Questionnaire found in the previous manual. The changes went into effect on December 7, 2020.
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Section 111 User Guide Update

NGHP Section 111 updated user guide was published. Check out the changes and read more below!
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One Week Reminder: Town Hall on NGHP Conditional Payments and Section 111 Reporting

Set your calendars for 1 PM, Thursday April 1, 2021 to hear from CMS . . .
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New Year, New Section 111 User Guide

CMS has started off 2021 with a bang. As we have seen over recent months, CMS has been rapidly updating the NGHP Section 111 User Guide, releasing version 6.0 on Oct. 5, 2020 quickly followed by version 6.1 on November 10, 2020, and now version 6.2 in January. Unlike some past iterations of the User Guide, this release provides a few crucial updates that could affect RREs in a big way.
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CMS Releases Updated NGHP Section 111 User Guide Providing Needed Clarity

On October 5, 2020 CMS issued an updated version of the of the MMSEA Section 111 NGHP User Guide. The latest version of the User Guide, version 6.0, clarifies the computation of TPOC amounts, confirms the fact that indemnity-only settlements do not need to be reported, and provides an updated list of excluded ICD codes for 2021.
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Double the Damages, Double the Motion, Double the Denial

MSP Double Damages action to continue despite SoL and settlement release arguments
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