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CMS provides Section 111 best practices, compliance tips, and common errors in recent webinar
December 15, 2022 · Medicare Insights Team
The Centers for Medicare and Medicaid Services (CMS) held a webinar on December 6, 2022, regarding Section 111 Non-Group Health Plan best practices, compliance tips and common errors. While the webinar touched on several different areas, we’ve compiled some important takeaways to better manage your Section 111 reporting obligations.
Settlements that only include indemnity payments should not be reported as a Total Payment Obligation to Claimant (TPOC)
Angel Pagan, the BCRC EDI Director, outlined what settlements should and should not be reported as TPOC in Section 111 reporting.
Indemnity-only settlements should not be reported as TPOC
Further, if the claim has a history of indemnity-only settlement and a subsequent settlement closing out medical benefits occurs, the past indemnity-only settlement should not be included in TPOC being reported for the settlement that had medical benefits included.
A settlement that includes medical benefits should be included as TPOC
When TPOC is reported, it should include all Medicare covered and non-covered medical expenses, indemnity, attorney fees, Medicare Set Aside totals or non-CMS-approved allocations, payout totals for annuities, settlement advances, and property damages.
A settlement closes one (or more) condition but leaves others open for future medicals
Claims often include multiple conditions for which the insurer has accepted ongoing responsibility for medicals (ORM). When a settlement closes and thus the ORM ends for one or more – but not all – of the medical conditions applicable to the claim, the responsible reporting entity (RRE) will use a two-step process to reflect this information in Section 111 reporting.
Send an updated record as follows:
- Enter ‘2’ in the Action Type
- Add in previously reported values for Social Security Number/Medicare number, CMS date of incident, plan insurance type, policy number and ‘Y’ in ORM indicator
- Confirm zeroes are in the ORM termination date field (Field 79)
- Enter ICD diagnosis codes for injuries for which the RRE continues to have ORM
- Do not enter ICD diagnosis codes for the injured that resulted in TPOC
Send an Add Record for the TPOC
- Enter ‘0’ in the Action Type
- Enter ICD diagnosis codes describing all injuries claimed and/or released relating to the TPOC
- Enter ‘N’ in the ORM indicator
- Enter TPOC dates and amounts
CMS’ Top error codes
While the webinar listed CMS’ top 10 error codes, the most notable were as follows:
- Inaccurate representative phone number causing a soft error.
- Invalid ICD code:
- Enter ICD codes without decimals to ensure it is correct
- Correct errors before the next quarterly file submission period
No updates on the civil monetary penalty final rule
CMS did not address the, still pending, civil monetary penalty (CMP) final rule. If a final rule is not set before the due date of February 18, 2023, the rule may have to restart the process. Optum will closely monitor the status of the CMP rule to see if it is finalized and will provide additional analysis and recommendations if/when that happens.
Optum offers Medical Claim Management to comply with Section 111 requirements
Based on the Proposed Rule on CMPs, one error on one claim could result in a CMP of $1,000 per day, up to $365,000 per year. That means ten claims out of compliance for a year could result in CMP exposure of $3,650,000. The potential risk of non-compliance with CMS’ Final Rule could be staggeringly high.
Optum’s cost-effective Medicare Claim Management product provides a detailed analysis of the entire claim to specifically identify areas at risk of CMPs along with recommendations to minimize risk of any penalties imposed by CMS. Additionally, the Medicare Claim Management product is designed to address other claim-related findings that could result in cost savings recommendations.
Optum’s Medicare Claim Management was developed to:
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For additional information on how Optum can help you with your Medicare Secondary Payer compliance needs and put you in the best situation to minimize your risk, please contact Michael Flower at Michael.Flower@optum.com or call at 813-627-2406.
