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
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.
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.