Author: Michelle Allan
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.
The webinar can be accessed via the following:
Date: Thursday, September 9, 2021
Time: 1:00 PM EST
Webinar URL: https://www.mymeetings.com/nc/join.php?i=PWXW2072062&p=9205987&t=c
and
Conference Dial In: (888) 469-1074
Conference Passcode: 9205987
Both the webinar link and conference call information above are necessary to access both the visual and audio portions of the presentation. Questions can be submitted in advance to PL110-173SEC111-comments@cms.hhs.gov by September 2, 2021.
The Centers for Medicare and Medicaid Services (CMS) has debuted details relative to the PAID Act (Provide Accurate Information Directly), a new law to be fully implemented by December 11, 2021, with more to come. The Act, signed into law on December 11, 2020, was 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.
Since the PAID Act was signed into law last year, the industry has been awaiting the technical specifications about how Medicare Part C and Part D information will be transferred between CMS and NGHP RREs. According to this law, CMS must provide RREs with each of a Medicare Beneficiary’s enrollments in Part C and/or Part D plans for the most recent three years via the Section 111 reporting query. This information can be utilized by NGHP RREs to determine which Part C and/or Part D plans may have recovery rights for Medicare Conditional Payments.
The PAID Act does not create the obligation for primary payers to reimburse conditional payments to Medicare Part C or Part D plans such as the Medicare Secondary Payer laws, which do require Part A/B reimbursements. However, in reliance on the Medicare Secondary Payer laws, Appellate Courts in multiple jurisdictions, including Pennsylvania, Delaware New Jersey, Florida, Alabama and Georgia, have created obligations to reimburse Part C/D plans. Ongoing litigation continues to expand this subset in a case-by-case manner. The PAID Act was designed to assist NGHP primary payers with the quandry of a having a legal obligation to reimburse Medicare conditional payments and no resource to identify which plans to repay. The PAID Act serves to eliminate the pay-and-chase method of attempting to satisfy reimbursement obligations.
While the government fleshes out the technical specifications associated with the PAID Act, the industry continues to wait for a final rule to be published regarding Section 111 reporting Civil Monetary Penalties. A draft rule was disseminated on February 13, 2020, with the Official Comment period closed in April of that year.
By way of history, this rule has been in progress since 2013, pursuant to the Strengthening Medicare and Repaying Taxpayers Act (SMART Act) of 2012, which amended the Medicare, Medicaid and SCHIP Extension Act of 2007. The 2007 law rocked the industry by calling for mandatory penalties against NGHP primary payers of up to $1,000 per day per claimant for failure to properly report Section 111 data to Medicare. The SMART Act softened this, making the penalty discretionary rather than mandatory. While the details of what would constitute a full penalty, diminished penalty and/or safe harbor from Civil Monetary Penalties have been referenced in the draft rule, this is not final and is thus subject to change.
Allan Koba Compliance Solutions continues to monitor advances relative to the PAID Act, and other Medicare Secondary Payer matters. To get more information, please contact us at: info@allankoba.com
Author: Michelle Allan
In conjunction with other ongoing efforts to notify Responsible Reporting Entities of updates relative to the PAID Act (Provide Accurate Information Directly), 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, accessible here:
According to the Changes for this Release page:
The following will become effective December 11, 2021: In 2020, the Provide Accurate Information Directly Act (PAID Act) was passed to help NGHP Responsible Reporting Entities (RREs) better coordinate benefits by providing additional beneficiary enrollment information. With this Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years, as well as the most recent Part A and Part B entitlement dates. To support this Act, the HIPAA Eligibility Wrapper (HEW) software will be updated and the X12 271 query formats will be modified to extract the additional fields (see 271 Eligibility Response Companion Document).
For this release, the Part C Medicare Advantage and Part D Prescription Drug Enrollment Data 271 eligibility response file tables have been updated to display the correct Segment IDs for Element IDs NM101-103. Additionally Part D contract information has been added (Table 26 and Table 27). Other changes have also been made to update and reorganize several tables.
In follow up to a webinar of June 23, 2021, releasing the first details about the new law implementation, CMS is hosting a second webinar to provide additional PAID Act details on September 9, 2021. The alert for the September 9 webinar can be accessed here:
Provide Accurate Information Directly (PAID) Act Testing Webinar Announcement (cms.gov)
The Centers for Medicare and Medicaid Services (CMS) has debuted details relative to the PAID Act (Provide Accurate Information Directly), a new law to be fully implemented by December 11, 2021, with more to come. The Act, signed into law on December 11, 2020, was 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.
Allan Koba Compliance Solutions continues to monitor advances relative to the PAID Act, and other Medicare Secondary Payer matters. To get more information, please contact us at: info@allankoba.com
Author: Logan Pry
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. Moreover, we now know the exact information to be provided as well as the response file layout. We have known that these changes were on the horizon since the signing of the PAID Act on December 11 of last year. However, receiving this information in June gives RREs a few months to implement the requisite changes to their own system and process in order to properly utilize the additional information that will now be returned on the query response file.
As a quick refresher, the PAID Act, in relevant part, requires that CMS expand its Section 111 query response data in order to identify whether an individual is, or has been, entitled to, Medicare Part C and/or Part D benefits within the last three years. It also requires CMS to provide the plan name and contact info for any positive results returned through this process.
Given the growing body of case law providing favorable recovery rights to Medicare Advantage plans and their assignees under the private cause of action of the Medicare Secondary Payer Act, identifying any Medicare Advantage coverage overlap and resolving any potential liens prior to, or as a part of, your settlement can be critical.
Although the PAID Act updates make up the majority of the changes to version 6.4 of the User Guide, there were other very important updates and a summary of the changes is outlined below:
Don’t forget to register for Allan Koba Compliance Solution’s debriefing webinar on June 24th discussing CMS’ PAID Act web conference, implementation of the changes being brought on by the PAID Act, and their effect on Section 111 reporting and conditional payment recovery.
Email info@allankoba.com to register for the June 24th Webinar.
For any comments, questions, or concerns regarding the newest updates to the NGHP User Guide, the PAID Act implementation, updates on Civil Monetary Penalties, and Section 111 reporting and conditional payment recovery efforts in general, please don’t hesitate to contact our reporting team at section111@allankoba.com.
Author: Michelle Allan
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.
According to the Alert disseminated today by the Centers for Medicare and Medicaid Services’ (CMS) Office of Financial Management Financial Services Group, webinar topics include an introduction of what the PAID Act is, details of the NGHP Section 111 query response file changes, information on the scheduled testing period and implementation timeframes. A Question and Answer session with both CMS staff and the Benefits Coordination and Recovery Center (BCRC) will follow. Details of the webinar are as follows:
Date: Wednesday, June 23, 2021
Time: 1:00 PM EST
Webinar URL: https://www.mymeetings.com/nc/join.php?i=PWXW2072056&p=9205987&t=c
Conference Dial In: 888-469-1074
Conference Passcode: 9205987
Since the PAID Act was signed into law on December 11, 2020, the industry has been awaiting the technical specifications about how Medicare Part C and Part D information will be transferred between CMS and NGHP RREs. According to this law, CMS must provide RREs with each of a Medicare Beneficiary’s enrollments in Part C and/or Part D plans for the most recent three years via the Section 111 reporting query. This information can be utilized by NGHP RREs to determine which Part C and/or Part D plans may have recovery rights for Medicare Conditional Payments. The PAID Act does not create the obligation for primary payers to reimburse conditional payments to Medicare Part C or Part D plans such as the Medicare Secondary Payer laws, which do require Part A/B reimbursements. However, in reliance on the Medicare Secondary Payer laws, case law in multiple jurisdictions has created such an obligation to reimburse Part C/D plans. Ongoing litigation continues to expand this subset in a case-by-case manner. The PAID Act was designed to assist NGHP primary payers with the quandary of a having a legal obligation to reimburse Medicare conditional payments and no resource to identify which plans to repay. The PAID Act serves to eliminate the pay-and-chase method of attempting to satisfy reimbursement obligations.
While the government fleshes out the technical specifications associated with the PAID Act, the industry continues to wait for a final rule to be published regarding Section 111 reporting Civil Monetary Penalties. A draft rule was disseminated on February 13, 2020, with the Official Comment period closed in April of that year.
By way of history, this rule has been in progress since 2013, pursuant to the Strengthening Medicare and Repaying Taxpayers Act (SMART Act) of 2012, which amended the Medicare, Medicaid and SCHIP Extension Act of 2007. The 2007 law rocked the industry by calling for mandatory penalties against NGHP primary payers of up to $1,000 per day per claimant for failure to properly report Section 111 data to Medicare. The SMART Act softened this, making the penalty discretionary rather than mandatory. While the details of what would constitute a full penalty, diminished penalty and/or safe harbor from Civil Monetary Penalties have been referenced in the draft rule, this is not final and is thus subject to change.
For more information about the PAID Act, Medicare Conditional Payment Reimbursement, Section 111 Reporting and Consulting, Civil Monetary Penalties or any other matters, please contact us at info@allankoba.com.
Author: Michelle Allan
Common Medicare Secondary Payer question: When is a Medicare Conditional Payment due? When the mail delivers anything with CMS letterhead prominent in the top left-hand corner, most payers recognize it needs some attention, particularly given the countless horror stories circulated within the insurance industry associated with failure to reimburse CMS.
But there are so many letters. And so many different kinds of letters. There are conditional payment letters (CPLs), and sometimes several of them. There are conditional payment notices (CPNs). Sometimes there are CPNs and CPLs. Then there may be disputes and more CPLs. Finally, there is a Demand for Reimbursement, which may seem as though the end is in sight. But even after reimbursement, there may be more CPNs, CPLs and Demands.
The barrage of various types of correspondence begs the question of when to pay Medicare back before any penalties, collections actions or lawsuits take place. During Medicare’s recent Town Hall held on April 1, questions dealing with this very issue were presented to a joint panel comprised of representatives from CMS, the BCRC and the WCRC. Some timely illumination may also arise from a recent class action dismissal in which the Middle District of North Carolina sheds light on ripeness for payment.
During CMS’s Town Hall conference call last week, there were several questions raised that were pertinent to a recent case out of the Western District of North Carolina that outlines the back and forth that can occur if you attempt to handle Medicare conditional payments prior to a demand being issued. In Sims v. PMA Insurance Company et al, the District Court dismissed a putative class action alleging failure to reimburse Medicare conditional payments. Certified nursing assistant Cathy Monroe Sims was injured at work on June 16, 2011. She became Medicare entitled on February 1, 2014. Some medical treatment had been denied and on May 15, 2015, the North Carolina Industrial Commission awarded ongoing medical care for her low back. On August 5, 2015, a Rights and Responsibilities letter was issued by CMS. On August 11, 2015, there was a CPL in the amount of $4,552.87, which was disputed and reduced to $2,397.39 by way of another CPL dated September 3, 2015. A third CPL was issued on March 15, 2017 for $6,166.31, which was disputed on February 8, 2018. The dispute was partially favorable, and the amount was reduced to $4,779.73 on March 1, 2018. This amount was disputed on April 6, 2018.
Despite all the back-and-forth correspondence, at no point did any of the letters issued from CMS ask for reimbursement. Rather, the letters said things like “still investigating this case file,” “not a final list and w[ould] be updated,” “This is not a bill,” “Do not send payment at this time,” and “refrain from sending any monies to Medicare prior to … receipt of a demand/recovery calculation letter.”
There had not been any further communication from CMS since the April 6, 2018 suit was filed. Specifically, no Demand had been issued.
Sims filed suit against the insurance company on March 16, 2020.
Once the complaint was filed, a new CPL was issued on April 15, 2020 in the amount of $10,859.34. This amount was disputed on April 23, 2020 and another letter dated May 4, 2020 indicated the dispute was favorable. The conditional payment amount had been adjusted down to zero.
On June 12, 2020, the Defense filed a 12(b)(6) motion for dismissal for lack of standing and/or failure to properly state a claim. The motion was based on a two-part defense, that Sims lacked standing because she had not suffered an injury in fact and also that the case was not ripe for adjudication.
The next filing was on August 5, 2020, which was an Amended Complaint that not only alleged a violation of the Medicare Secondary Payer act, but also sought class certification.
The Court was tasked with determining whether the Defendant’s failure to reimburse Medicare was final and not dependent on future uncertainties. The Court ultimately agreed with the Defense that whilst CMS and the insurance company were working out the reimbursable conditional payment amount, the matter was not ripe for adjudication because there remained future uncertainties about the amount at issue. Also, failure to reimburse Medicare at this point did not result in any actual harm to Sims. The Court quoted Miller v. Brown, 462, F.3d 319 (4th Cir. 2006) stating “A case is fit for judicial decision when the issues are purely legal and when the action in controversy is final and not dependent on future uncertainties.”
Sims’ position was that the obligation to reimburse Medicare became final after CMS responded to the dispute of February 8, 2018. Specifically, the Court stated, “This correspondence and dispute process, coupled with CMS’s revisions to the conditional payments owed, indicate that Defendants’ failure to reimburse Medicare was not final. Defendants’ requirement to reimburse Medicare remains contingent upon it being determined with appropriate finality that Defendants owe Medicare reimbursement (for example, by CMS issuing a demand recovery letter.)”
There is a footnote at the end of the case that references the factors at play in a private cause of action case, those being the existence of (1) a primary plan, (2) that is responsible to pay for an item or service, and (3) that failed to make the appropriate payment to Medicare for an item or service. Most written judicial opinions focus on whether there is a primary plan and whether the plan has a demonstrated responsibility to pay for items or services. Whether or not the amount is actually due to Medicare is rarely addressed.
Primary payers in workers’ compensation plans have various options in how they can address Medicare Conditional Payments. After the Ongoing Medical Responsibility (ORM) is reported to Medicare through Section 111 reporting, conditional payments can be researched and tallied up as the claim is litigated. Under the Medicare Secondary Payer laws, Medicare has the right to seek reimbursement for any amounts paid conditionally during the course of the claim, up until the time of final settlement when the obligation to pay for medical care concludes by settlement, judgement, award or other payment. One of the complicating factors in settling cases that involve potential Medicare Conditional Payments is that the amount to reimburse can fluctuate as the case progresses, as was the case in Sims. This can occur for myriad reasons, including but not limited to technological functionality, the quality of information conveyed to CMS via Section 111 reporting, changes in relatedness, compensability, coverage, or law, the timeliness of medical providers, suppliers and facilities in submitting bills to Medicare for payment and, of course, the passage of time between various pieces of correspondence, such as the CPLs, CPNs, disputes, determinations, Demands and more.
At the conclusion of a claim, when an ORM is terminated and/or a final settlement agreement is sent to CMS, a Demand will be issued. This is a bill. It will state clearly on the document that it is a Demand for Reimbursement, when the amount is due, what the due amount is, and what the penalty is for failure to make timely payment, which is generally an interest rate hovering around 10%.
Since a conditional payment amount can ebb and flow throughout the claim, a best practice is to review amounts on the portal, wait until about 30-90 days out from settlement to dispute, and then reimburse Medicare when the Final Demand for Reimbursement is received. Otherwise, parties to settlement will find that numerous disputes may be needed as a case progresses, creating waste in terms of time, effort and possible vendor or legal fees to do so. If things do not resolve at the point of Demand, any post-Demand conditional payment controversies can be appealed through the Medicare Hearings and Appeals process from that point forward. Further, payment of a conditional payment amount prior to a Demand can result in accounting misfires; specifically, in that the payment may not be directly applied to the debt at issue.
Medicare Conditional Payments are complex. Allan Koba Compliance Solutions experts have been managing Medicare Conditional Payment programs for nearly two decades. In our role as a Recovery Agent for insurance companies, self-insured businesses, third party administration companies and governmental entities, we efficiently and competently manage the payer’s entire Medicare Conditional Payment program. To discuss how Allan Koba Compliance Solutions can be of service to your business, please contact us at: info@allankoba.com
Author: Logan Pry
In the fourth iteration of the NGHP Section 111 User Guide in six months, CMS has issued several updates, mainly affecting technical aspects of Section 111 reporting. The bulk of these updates attempt to clarify how and when errors will be received through the reporting process. As we know, the proposed regulations regarding civil monetary penalties put out last year, with public comment period running through April 2020, outlined an ‘error threshold’ as a possible way for an RRE to be penalized for noncompliance. The continued updates on Section 111 errors and clarification on the same seems to indicate that CMS still has CMPs and specifically, the error threshold, in its crosshairs.
In short, version 6.3 of the User Guide provides clarification that individual payments to account for lost wages are not individual TPOC events; it confirms an extensive list of ‘soft errors’ (i.e. errors that will not cause a claim input file to be rejected due to error threshold, but should still be corrected and resubmitted); it confirms that error code CP13 for no-fault limit is now effective (as of 4/5/21); it confirms the elimination of the SP31 disposition code in favor of disposition code 03 in the event that a record is submitted prior to the individual’s date of entitlement; and finally, it adds clarification to the CP11 error for reporting no-fault insurance limit.
A full summary of updates in version 6.3 of the User Guide, as well as the section in which these updates are found are as follows:
Ch. III
Ch. IV
Ch. V
Version 6.3 of the User Guide in its entirety can be found here:
Allan Koba continues to stay committed to bringing you the latest updates from CMS on all things MSP compliance. Please contact our Section 111 Reporting team at Section111@allankoba.com to discuss the newest updates to the NGHP User Guide and Section 111 reporting in general, updates on Civil Monetary Penalties, changes to Section 111 reporting as a result of the PAID Act, and how we can assist you with a Section 111 Diagnostic Evaluation to ensure your Section 111 reporting remains compliant.
Author: Allan Koba Compliance Solutions
Set your calendars for 1 PM, Thursday April 1, 2021 to hear from CMS in a Town Hall about “common NGHP topics.” In an alert dated February 25, 2021, CMS stated that representatives from the Centers for Medicare and Medicaid Services, the Benefits Coordination & Recovery Center (BCRC) and the Commercial Repayment Center (CRC) will be on hand to answer questions about Section 111 reporting and conditional payment recovery. Participants can access the audio and visual portions of the presentation as follows:
Webinar URL: https://www.mymeetings.com/nc/join.php?i=PWXW2033201&p=7654759&t=c
Conference Dial In: 888-972-6409
Conference Passcode: 7654759
Author: Logan Pry, Compliance Manager
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.
In sum, CMS has made a handful of changes, including permitting RREs to report an ORM termination date of up to 75 years in the future (previously, RREs were only permitted to report an ORM term date up to 6 months in advance or be subject to error). The Policy Number field is now considered a ‘Key Field’ for submitting updates and delete records. That is, in order for CMS to successfully update or delete a previously reported record, the policy number must match exactly to that of the previously accepted claim. This has an additional impact on the action type field for reporting purposes- in the event that an RRE needs to update a policy number on a previously accepted claim, it must submit the action type as a delete/add as opposed to an update record.
Further, CMS has issued updates changing one of the methods of data transmission, eliminating a past option for data transfer and replacing with a new option. CMS has also confirmed that the threshold for trauma-based liability insurance settlements, no-fault insurance, and workers’ compensation settlements will remain at $750 so long as there is no ORM. Finally, a retraction has been issued. CMS previously announced that error code CP03 (an error in the office code field) would trigger a ‘soft error’, this error will no longer be considered a soft error and will be considered in triggering the error threshold on a claim input file.
These updates also indicate that at least one more iteration of the User Guide will be coming in April of this year.
A full summary of updates, as provided by CMS in version 6.2, as well as the section in which these updates are found are as follows:
Ch. II
Ch. III
Ch. IV
Ch. V
Version 6.2 of the User Guide in its entirety can be found here:
The PAID Act:
This release comes on the heels of the PAID Act being signed into law on December 11, 2020. In short, the PAID Act expands the Section 111 Medicare query process to require CMS to provide an RRE with any Medicare Part C and/or Part D entitlement information within the preceding 3-year lookback period. In addition to entitlement information, if applicable, the RRE must also be provided with the names and addresses of those plans. While version 6.2 of the NGHP User Guide does not yet address the mandatory updates outlined by the PAID Act, the rapid review and amendment of the User Guide seems to imply that it is on CMS’ radar, not to mention that the PAID Act specifically states that the updates to the Section 111 Query process must be in place by December 2021. This tight timeline indicates that there will be more information to come regarding changes to the Section 111 process.
In light of this release and the PAID Act being signed into law, it is becoming increasingly more important to ensure that your Section 111 reporting program is in compliance with CMS’ current guidance. Areas of focus should include ensuring that claims that meet all applicable reporting thresholds are reported in a timely manner, that claims are reported error-free, and that conflicting information is not being provided.
Allan Koba continues to stay committed to bringing you the latest updates from CMS on all things MSP compliance. Please contact our Section 111 Reporting team at Section111@allankoba.com to discuss the newest updates to the NGHP User Guide and Section 111 reporting in general, Civil Monetary Penalties, the PAID Act, and how we can assist you with an internal audit and ensure your Section 111 reporting remains compliant.
Author: Ciara Koba and Melanie Schafer
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, and they are designed to modify and streamline the questions that providers should be asking Medicare beneficiaries that they are treating upon the start of care.
By way of context, the Medicare Secondary Payer Act (MSP) indicates that CMS pays primary unless there is a discrete alternative carrier which should pay primary. Where there is such an alternative carrier, that carrier pays primary, and where the facts and circumstances give rise to settlement, CMS’s interests must be protected.
What this means from a practical standpoint is that over time CMS has been refining its methods for determining the existence of an alternative payer which should pay primary and whether a settlement has been effectuated such that proceeds from settlement must be exhausted before CMS will pay for related treatment. While the MSP allows CMS to make provisional payment where such an alternative payer exists, and allows CMS to seek reimbursement for any payments made, recent refinements to CMS policy have been aimed at preventing such provisional payments and therefore avoid the need to seek subsequent reimbursement.
This is a good thing for CMS because it preserves the Medicare trust fund. It removes CMS and their recovery contractors from a “pay and chase” scenario and it places a strict requirement on providers to make sure they are asking the right questions to prevent CMS from being billed in the first place. Overall, if this process is followed consistently, the volume of Medicare conditional payments being made should decrease.
The questions themselves are geared towards uncovering specific claim/policy numbers and dates of illness/injury such that the provider is able to bill the liability, workers’ compensation or no-fault carrier instead of Medicare. Unfortunately, this line of questions may not prevent Medicare from being billed during the initial visit due to the fact that a claim number is not yet available. That being said, this should catch most auto and no-fault claims and it may even catch a number of WC claims especially when Medicare beneficiaries change providers. Further, it will uncover whether Medicare is primary or if another primary payer exists.
A full list of the new questions can be found here: https://www.cms.gov/files/document/r10359MSP.pdf.
As always, we will continue to provide updates on any changes to CMS’s policies that affect the MSP industry. If you have any questions or concerns about this or any other MSP issues, please contact us at info@allankoba.com.
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. These updates come at an opportune time considering the additional information being disseminated regarding Section 111 civil monetary penalties. Further, RREs are questioning their responsibilities over reporting indemnity-only settlements. This exact question was raised on several occasions during this month’s Annual NAMSAP Conference, and in light of potential misinformation being put out by others offering Section 111 services, this clarification comes at a great time.
A full list of the updates made to Version 6.0 of the User Guide is as follows:
– Ch. III of the User Guide added additional information regarding the computation of TPOC Amounts. Specifically, Ch. III Sect. 6.4 (pg. 6-13) now states:
“The computation of the TPOC amount includes, but is not limited to, all Medicare covered and non-covered medical expenses related to the claim(s), indemnity (lost wages, property damages, etc.), attorney fees, set-aside amount (if applicable), payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), and amounts forgiven by the carrier/insurer.”
– Ch. III also now includes additional information regarding the reporting of indemnity-only settlements. Specifically, Ch. III Sect. 6.5.1 now states:
“RREs are not required to report liability insurance (including self-insurance) settlements, judgments, awards or other payments for “property damage only” claims which did not claim and/or release medicals or have the effect of releasing medicals. Similarly, “indemnity-only” settlements, which seek to compensate for non-medical damages, should not be reported. The critical variable to consider is whether or not a settlement releases or has the effect of releasing medicals. If it does, regardless of the allocation (or lack thereof), the settlement must be reported.”
– Finally, Ch. V has updated the list of no-fault excluded ICD-10 diagnostic codes for fiscal year 2021.
Version 6.0 of the NCHP Section 111 User Guide can be downloaded here (https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-User-Guide/NGHP-User-Guide).
While the speculation continues to grow as to when CMS will complete its review of the public comments received on the advanced notice of proposed rulemaking, and more importantly make any announcement as to where we stand on final regulations regarding the implication of civil monetary penalties, one thing is clear- CMS appears to be moving in the direction of CMPs. Accordingly, it is increasingly important to ensure that your Section 111 reporting program is running efficiently, and you are in compliance with CMS’ current guidance. The best way to ensure compliance is to run an internal audit of your Section 111 data in order to confirm claims meeting all thresholds are being reported accurately and timely, that contradictory information is not being reported, and your reporting is error-free.
We at Allan Koba Compliance Solutions will continue to provide you with the latest updates from CMS on all things MSP compliance. Please contact our internal Section 111 Reporting team at info@allankoba.com to discuss the newest updates to the NGHP User Guide, Civil Monetary Penalties, and how we can assist you with an internal audit and ensure your Section 111 reporting remains compliant.