CMS recently announced an upcoming informational webinar for Non-Group Health Plans (NGHPs) regarding Medicare Secondary Payer (MSP) and Civil Money Penalties (CMPs).

This informational webinar is set for Thursday, October 17, 2024 at 1:00pm Eastern. CMS plans to include reminders about the Final Rule, will discuss their auditing process, cover important dates, and host a Q&A session. Responsible Reporting Entities (RREs) and other key stakeholders are encouraged to submit questions in advance to Sec111CMP@cms.hhs.gov. Click here for registration information.

CMS Released a Webpage Dedicated to the CMP Process

The new CMP web-based information may be found here, and covers the Final Rule extensively. We are highlighting a few important areas to focus on:

How do I Keep Compliant with the Final Rule?

CMS requires the Total Payment Obligation (TPOC) or assumptions of Ongoing Responsibility for Medicals (ORM) for a Medicare beneficiary to be timely reported, which is defined as within 1 year (365 days) of the reportable MSP occurrence.

Penalties for Non-Compliance are Tiered as Follows:

*All penalties subject to inflation adjustments

Final Rule is Prospective rather than Retrospective

Because civil money penalties only affect prospective claims, retrospective claims will not be subject to civil money penalties. Any record with a TPOC or ORM acceptance prior to October 11, 2024, will not be subject to a civil money penalty. While such older claims may not be subject to penalties, they could still result in other consequences, including conditional payments and potentially a False Claims Act suit.

CMS Audits

Beginning in 2026 and continuing on a quarterly basis, CMS will audit 250 MSP records for compliance. The 250 records per quarter will be pro rata, consisting of a mix of group health plan (GHP) and NGHP records. It is possible (though unlikely) that a single claim could be pulled multiple times based on entry of an ORM and TPOC (or multiple TPOC entries on the same claim).

CMS CMP Letters and Timelines

In the event an audit reveals non-compliance, an informal notice will be sent to the RRE’s authorized representative with copy issued to the Account Manager.

• The first letter is issued when a noncompliant record is identified on CMS’ quarterly audit. This informal notice is not a CMP being assessed, but rather an opportunity for the RRE to investigate and respond informally to CMS with mitigating evidence within 30 days of receipt of the letter. If CMS agrees with the mitigating evidence submitted, a CMP will not be issued.
• If CMS does not find the mitigating evidence persuasive or the RRE fails to submit anything to CMS in the 30 day period, then CMS will issue a formal CMP via Certified Mail. The informal appeal process will no longer be available at that point, and the RRE will need to request a hearing within 60 days of receipt of the Notice of Proposed Determination should they wish to appeal.
• If the RRE either does not request a hearing or exhausts all appeal rights, a Notice of Final Determination will be issued confirming the CMP is final.
  
  

ECS Can Help Assist with Your Section 111 Reporting Needs

ECS and our expert Section 111 team is available to assist you with your reporting needs and help make sure your claims are timely reported to CMS to avoid costly CMPs. We will continue to keep readers apprised of further agency developments from CMS as we monitor this and all areas of MSP compliance closely. ECS Section 111 reporting clients should address any questions to their assigned MMSEA Compliance Manager or via email at MIRService.Support@examworkscompliance.com. Should you have any questions on these developments please contact Michael Flower at 678-222-5409 or Michael.Flower@ExamWorksCompliance.com.