Latest CMS Webinar Reminds Insurance Industry Medicare Civil Money Penalty Clock is On!
Rafael Gonzalez, Esq.
speaker, blogger, podcaster, adjunct, attorney providing medicare/medicaid counsel nationwide on secondary payer issues in liability, no-fault, and work comp claims and litigated cases
On October 17, 2024, the Centers for Medicare & Medicaid Services (CMS) hosted its latest Medicare Secondary Payer (MSP) Civil Money Penalties (CMP) webinar for non-group health plans (NGHP). What follows are the top 20 updates and reminders from CMS regarding the applicability and enforcement of CMPs for noncompliance mandatory insurer reporting (MIR) Section 111:
1.??Civil money penalties final rule became applicable as of October 11, 2024. This is the start of the compliance clock in as far as timely reporting of MSP occurrences, timely reporting of acceptance of ongoing responsibility for medical (ORM) and total payment obligation to claimant (TPOC).
2.??Civil money penalties enforcement date is October 11, 2025. In other words, MSP occurrences of ORM and TPOC dated on or after October 11, 2024, must be reported within 365 days, or by October 11, 2025.
3.??A Responsible Reporting Entity (RRE) is considered to have reported timely, and therefore compliant with mandatory insurer reporting requirements if the TPOC record is reported within 365 days of the date of the settlement, judgment, award, or other payment.
4.??An RRE is also considered to have reported timely and therefore compliant with MIR requirements if the effective date of ORM care has been assumed on the date of incident or the date the beneficiary became entitled to Medicare, whichever is later.
5.??CMS again reminded that it is not the reporting agent’s responsibility to ensure MSP records are submitted to CMS on a timely manner, as that legal responsibility belongs to the RRE.
6.??Based on statutory authority at 42 USC 1395y(b) and the most recently adopted and now final federal regulations, CMS reminded listeners of the penalty amount to be assessed per day per file for noncompliant NGHP records.
7.??If an RRE is late in reporting ORM and TPOC more than one year, but less than two years, the daily civil money penalty is $250, which after adjusted for inflation in 2024 equals $357.
8.??If an RRE is late in reporting ORM and TPOC more than two years, but less than three years, the daily money penalty is $500, which after adjusted for inflation in 2024 equals $714.
9.??If in RRE is late in reporting ORM and TPOC more than three years, the daily money penalty is $1,000, which after adjusted for inflation in 2024 equals $1,428.
10.? Civil money penalties, for any one instance of noncompliance, are capped at $365,000 on annual basis.
11.? CMS reminded listeners that should CMS exercise its right to levy a penalty, civil money penalty correspondence will be mailed to the RRE’s account representative on record, with a copy to be mailed to the account manager. However, reporting agents will not receive any such civil money penalty correspondence.
12.? Therefore, it is the RRE’s responsibility to ensure all contact information in the MIR system is up-to-date. RREs will be held accountable should any civil money penalty correspondence be missed due to inaccurate, outdated, or wrong contact information.
13.? If an RRE needs to replace, change, update, or in any way amend its authorized representatives or contact information, the RRE’s assigned EDI representative can help and should therefore be contacted.
14.? CMS reminded listeners that its first audit will include records from the fourth quarter of 2025, since the compliance clock began on October 11, 2024, and all MSP occurrences must be reported within 365 days, or October 11, 2025.
15.? CMS will pick a random sample of 250 new accepted records per quarter, proportionately representing GHP and NGHP records received through both section 111 and non-section 111 submissions.
16.? CMS reminded listeners that RREs must make a total of three good faith attempts to obtain information on reportable claims. A minimum of two attempts must be mailed or emailed to the beneficiary and the attorney, while a third attempt can be made via phone, call, mail, or email.
17.? If the necessary methods of communication are attempted and appropriately documented, then the safe harbor would have been reached and the RRE would be excused from reporting ORM and TPOC on the claim.
18.? CMS again reminded listeners that civil money penalties will only be issued prospectively. In other words, a record occurring on or after October 11 of 2024 with an ORM or TPOC reportable event.
19.? In situations where a record has been rejected because of an error, a corrected record must be resubmitted within 365 days of the MSP occurrence, that is the date of ORM acceptance and TPOC date of settlement, judgment, award, or payment, not the date on which the error was found or communicated.
20.? CMS announced that the letters to be sent to RREs during the informal and formal civil money penalty process, as well as the appeals process available to RREs, will be discussed in more detail at a future webinar.
We Can Help ?
To help with all of these issues, our firm offers “MIR Audits,” in which we look at our client’s raw reporting data, its sharing of such data with any outside entity such as a reporting agent, and ultimately the reporting of such data to Medicare and its timeliness and accuracy. We provide our clients a comprehensive report detailing MIR status, findings, and recommendations on each audited file.
Our MIR Audits focus on three major factors: 1) ORM, which refers to the RRE’s responsibility to pay, on an ongoing basis, for the Medicare beneficiary’s medical care associated with a claim; 2) TPOC, which refers to the dollar amount of a settlement, judgment, award, or other payment in addition to or apart from ORM; and 3) Reimbursement and recovery of conditional payments. No MIR Audit should be complete without providing a review, analysis, breakdown, observations, conclusions, and recommendations regarding all conditional payment requests, disputes, demands, appeals, and recovery pending at both CMS recovery contractors.
To learn more about our firm, our services, and our MIR Audits, please visit us at?www.cattielaw.com, email us at?[email protected], or call us at 844.546.3500. In addition, you may follow us on LinkedIn, Twitter, and YouTube for updates and announcements on all components of Medicare Secondary Payer law and compliance.