For the first time in several years, the Centers for Medicare & Medicaid Services held a Section 111 NGHP Town Hall webinar. The webinar focused on common issues that arise in the mandatory insurer reporting process. While the scripted portion of the webinar was relatively uneventful, CMS provided important information in a lively question and answer discussion. Here is the critical information non-group health plans (NGHPs) need to know.

Scripted Portion

The scripted portion of the webinar was handled by Angel Pagan of the Benefits Coordination & Recovery Contractor (BCRC).  BCRC and CMS representatives covered a number of Section 111-related topics during the scripted portion of the call, including:

• Tips on Changing Agents. When a responsible reporting entity (RRE) changes agents, the RRE and the new reporting agent should not be obtaining a new RRE ID.  The new agent should report using the old RRE ID wherever possible.
• Tips on Reporting Proper ICD-9 and ICD-10 Diagnosis Codes. CMS and BCRC representatives reminded RREs and reporting agents that only relevant injury information is to be reported and that the “NOINJ” code should only be reported in very limited liability settlement situations.
• Multiple Submissions. RREs were reminded that off-cycle reporting is an option for reporting, particularly in situations where an ORM termination date can be reported.  The only restriction on off-cycle reporting is that RREs must wait for any prior claim input files to complete processing before the off-cycle reporting will be accepted.
• Mandatory Reporting Thresholds. BCRC and CMS representatives reiterated that the mandatory reporting thresholds are set at $750.  These thresholds do not apply to situations involving implantation, ingestion, or exposure.  During a question and answer section, CMS’ Jackie Cipa explained that statutory language does not permit CMS to extend these thresholds to settlements involving implantation, ingestion, or exposure.
• PIP and Med-Pay. BCRC and CMS representatives reminded RREs that PIP and med-pay limits should be pooled (if applicable) to ensure that the appropriate policy limits are reported.
• CMS Provided an Overview of Common Error Codes. The top-5 errors include: CI04 (State of Venue); CI05 (ICD Code 1); CJ01 (ORM Indicator); CJ07 (ORM=No but no TPOC reported); and TN99 (TIN errors)
• CMS Outlined Past and Future Enhancements to the Medicare Secondary Payer Recovery Portal (MSPRP). Our overview of these changes can be found here.

Following the scripted portion, BCRC and CMS representatives took questions from industry representatives.  The most important of these questions was actually “seeded” by CMS.  CMS addressed the question of indemnity-only workers’ compensation settlements.  For the last decade, workers’ compensation practitioners have relied upon general guidance to make their own determination of whether indemnity-only workers’ compensation settlements qualify as a total payment obligation to the claimant (“TPOC”) event, which is subject to mandatory reporting requirements when a Medicare beneficiary is involved.  CMS representatives answered the question unequivocally, noting that indemnity-only settlements are not TPOC events because they do not release a claim for medical benefits – they are simply releasing the wages portion of a claim. 

The announcement will not have major impact for many responsible reporting entities (RREs).  Nevertheless, for those who have either reported indemnity-only settlements in the past as a TPOC event or are unsure of how to proceed, the best approach is as follows:

• For any indemnity-only settlement, where medical is not included in the settlement, and where medical will either remain open or unresolved after the indemnity settlement, the indemnity settlement is not reportable as a TPOC.
• If an indemnity-only settlement has occurred, and medical is subsequently settled, a TPOC must be reported. The TPOC date should be the date of the medical settlement.  The amount should be the amount of the medical settlement.  The prior indemnity settlement should not be pooled with the medical settlement for the TPOC amount.
• It’s important to emphasize that full and final settlements that involve both medical and indemnity should be reported with the full amount of medical and indemnity as the TPOC amount.

Medicare’s Section 111 User Guide runs five volumes and hundreds of pages, yet for the last ten years virtually nothing has been said about indemnity-only settlements.  The answer provided on the Town Hall call is not currently included in the Section 111 User Guide.  We hope that CMS continues to amend the User Guide to include this guidance, in writing.

CMS and BCRC representatives answered a variety of other questions, including questions about ICD codes, future calls on civil monetary penalties, Medicare Advantage Plan access to Section 111 data, and more.  A full transcript of the call as well as copies of the slides will be available on CMS’ web site within the next week or so.

ECS has the largest and most experienced team of Section 111 reporting experts in the country. If you have any questions about the Town Hall call or looming civil monetary penalties, please reach out to our team to check on your existing Section 111 reporting process. If you have an obligation to report but have not yet registered – do not delay. Contact our Mandatory Insurer Reporting Team at MIRService.Support@examworkscompliance.com or 678-222-5454 to schedule an evaluation today.