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.
Since CMS review of a WCMSA is not a legal requirement, myriad Medicare Set-Aside products have been introduced to the workers’ compensation industry that allocate future Medicare-covered medical treatment in an effort to consider and protect Medicare’s interests without obtaining formal approval from Medicare. These allocations are usually marketed as protective solutions that save time and money by sidestepping Medicare’s rigid allocating methodology, avoiding lengthy review times and eliminating the risk of unpredictable and unjust outcomes. Common products include Evidence-Based Medicare Set-Asides and Non-Submit MSAs.
And now, so many years later, Medicare weighs in with the knockout punch: “… CMS treats the use of non-CMS-approved products as a potential attempt to shift financial burden by improperly giving reasonable recognition to both medical expenses and income replacement. As a matter of policy and practice, CMS will deny payment for medical services related to the WC injuries or illness requiring attestation of appropriate exhaustion equal to the total settlement less procurement costs before CMS will resume primary payment obligation…” (emphasis added.)
In its entirety, the update, entitled “4.3 The Use of Non-CMS-Approved Products to Address Future Medical Care” states:
A number of industry products exist with the intent of indemnifying insurance carriers and CMS beneficiaries against future recovery for conditional payments made by CMS for settled injuries. Although not inclusive of all products covered under this section, these products are most commonly termed “evidence-based” or “non-submit.” 42 C.F.R 411.46 specifically allows CMS to deny payment for treatment of work-related conditions if a settlement does not adequately protect the Medicare program’s interest. Unless a proposed amount is submitted, reviewed, and approved using the process described in this reference guide prior to settlement, CMS cannot be certain that the Medicare program’s interests are adequately protected. As such, CMS treats the use of non-CMS-approved products as a potential attempt to shift financial burden by improperly giving reasonable recognition to both medical expenses and income replacement.
As a matter of policy and practice, CMS will deny payment for medical services related to the WC injuries or illness requiring attestation of appropriate exhaustion equal to the total settlement less procurement costs before CMS will resume primary payment obligation for settled injuries or illnesses. This will result in the claimant needing to demonstrate complete exhaustion of the net settlement amount, rather than a CMS-approved WCMSA amount.”
Leaning on federal regulation for support, Medicare’s update plainly sets forth its refusal to pay for claim-related treatment post-settlement unless an approved WCMSA amount is properly exhausted. The alternative to obtaining an approved WCMSA is that exhaustion of the entire net settlement amount must occur before Medicare will make post-settlement claim-related payment. To be clear, the update does not suggest that Medicare will pursue action against primary payers for failure to obtain or fund an approved MSA value; rather, the clarification identifies the Beneficiary’s future entitlements as jeopardized if the net settlement amount is not used in its entirety for payment of claim-related Medicare-covered medical treatment. The referenced federal regulation lends the necessary authority to support Medicare’s position.
The allure of non-submit programs began in the early days of WCMSA review. The review program, initially performed by the CMS regional offices, had a slow start in the mid-aughts, plagued by mysterious allocation practices as well as pricing, allocating and rationale inconsistencies and ruinously long turnaround times. By 2012, approvals were rolling out within 30-90 days, with current times now as quick as two weeks. And with centralized review from a single Workers’ Compensation Review Contractor armed with detailed direction from the Agency, the evolution of methodology has become more and more consistent and straightforward. Additionally, transparency has improved in tandem with industry communication and the willingness of the government to openly exchange information. While not a perfect process, at this point in the lifespan of Medicare Set-Asides, improvements have reshaped the landscape, alleviating many of the concerns that commonly gave rise to consideration of non-submit MSAs.
Historically, the Medicare Set-Aside industry has developed a litany of non-submit products designed for cost-savings throughout the years, including allocations utilizing co-pay and deductible methodology for pharmacy pricing, formerly known as “donut-hole” allocations, as well as Medicare Set-Asides with values backed by “guarantee programs,” or insurance policies, negating the need for formal CMS approval of the allocation.
Is it time to update my Medicare Set-Aside program? Is there any place in my program for Evidence-Based or Non-Submit MSAs? Does my program address the risks associated with Medicare Secondary Payer laws? If you are pondering any of these questions or others, reach out to an Allan Koba Compliance Solutions professional at: info@allankoba.com. Our promise is to deliver effective solutions in a prompt, clear and efficient manner.
And for more information, stay tuned for Michelle Allan and Ciara Koba’s upcoming webinar on this Reference Guide update, coming soon to a WebEx near you…
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.
On December 15, 2021, CMS disseminated its annual alert for Computation of Annual Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards, or Other Payments for 2022. As per the SMART Act of 2010, this low dollar threshold renews on January 1, 2022, such that settlements of $750 or less do not need to be reported and Medicare’s conditional payment amount related to these cases would not need to be reimbursed.
Rulemaking believed to promulgate formality to Liability and No-Fault Medicare Set-Asides has been on the radar for several of years now, with no hint of detail.
The Abstract states that the rule “would clarify existing Medicare Secondary Payer (MSP) obligations associated with future medical items services related to liability insurance (including self-insurance), no fault insurance, and workers’ compensation settlements, judgments, awards, or other payments. This proposed rule would also remove obsolete regulations.”
Previous iterations of the Abstract used language such as:
“Currently, Medicare does not provide its beneficiaries with guidance to help them make choices regarding their future medical care expenses when they receive automobile and liability insurance (including self-insurance), no fault insurance, and workers’ compensation settlements, judgements, awards, or payments, and need to satisfy their Medicare Secondary Payer (MSP) obligations.”
And
“This proposed rule would ensure that beneficiaries are making the best healthcare choices possible by providing them and their representatives with the opportunity to select an option for meeting future medical obligations that fits their individual circumstances, while also protecting the Medicare Trust Fund.”
What has not changed in the Abstract is Medicare’s suggestion that any proposed rule will be voluntary in nature, although the “Significant” status broaches the possibility that there could be a policy concern or legal mandate involved.
Unsure of whether to report a claim? Concerned with Medicare Conditional Payment obligations? Wondering how to protect entitlements in liability or no-fault matters? Better not pout, better not cry. Just message an Allan Koba Compliance Solutions professional at Info@allankoba.com.
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.
The first alert, released October 26, 2021, provides RREs with a reminder to update their Section 111 reporting when applicable. Specifically, here, RREs are being reminded to update their No-Fault policy limit in the event that it changes. The alert provides the following example – “a policy allows for a minimum amount of MedPay coverage and will only allow a higher amount under certain circumstances, and those circumstances are not yet met at the time of reporting, the RRE should report the lower amount. Should the criteria that triggers the higher policy limit be met after that report, the RRE should update the record as soon as possible.” The alert goes on to remind us that reporting incorrect information, or failing to update the claim record as needed can put the RRE at risk of non-compliance with the Section 111 reporting requirements.
The full text of the alert can be found here – https://www.cms.gov/files/document/alert-reporting-incorrect-no-fault-policy-limits.pdf.
The second alert, released November 3, 2021, reminds RREs that in the event that funding of a settlement, or TPOC, is delayed until after the settlement date, the RRE should report the actual, or estimated, date of the funding in field 82 of the claim input file – “Funding Delated Beyond TPOC Date”. Failing to use this field when funding is delayed can cause CMS to initiate recovery demands before funds for the settlement have been received by the beneficiary. Obviously, this can negatively impact the beneficiary, can cause confusion and additional work for all parties involved. In addition, this field is available to RREs to ensure that they may still report TPOC events in a timely manner pursuant to current reporting guidelines on timely reporting, even when funding may be delayed for any reason.
The full text of this alert can be found here – https://www.cms.gov/files/document/alert-use-funding-delayed-beyond-tpoc-start-date-field.pdf.
These alerts serve as a helpful reminder as we move toward the end of the year to ensure that your Section 111 Reporting program is in full compliance with current guidance in light of information received about the proposed rules for civil monetary penalties over the last year, as well as the implication of the PAID Act updates to the query process.
Allan Koba Compliance Solutions continues to monitor updates to the Section 111 Mandatory Insurer Reporting requirements as well as all other Medicare Secondary Payer matters. For questions and more information, please contact us at info@allankoba.com.
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
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
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.
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.
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
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.
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