Franco Signor
Section 111 of the Medicare, Medicaid and SCHIP Extension Act
of 2007
Bennett L. Pugh
Franco Signor
1618 Montgomery Hwy. Suite 104 #278
(205) 901-1116
www.francosignor.com
Franco Signor
Law states:
• Beginning July 1, 2009, “liability insurance including self insurance, nofault insurance, and workers’ compensation laws and plans” must report
claims involving a Medicare beneficiary to Medicare when the claim is
“resolved (or partially resolved) through a settlement, judgment, award, or
other payment on or after July 1, 2009.”
• “Must also report on all claims for which the [responsible reporting entity]
still has responsibility for ongoing payments for medical services as of
July1, 2009,” such as open medicals in workers’ compensation claims.
– Dates have been revised.
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Section 111 Notification Requirements
• To assist Medicare with recovery of CPC’s and
to keep Medicare from paying when a primary
payer exists (or arguably exists), the law now
imposes obligation to notify Medicare of
primary payer situations starting in 2009.
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Who is the RRE?
According to CMS . . .
• “For re-insurance, stop loss insurance, excess insurance, umbrella
insurance, guaranty funds, patient compensation funds, etc. which have
responsibility beyond a certain limit, the key in determining whether or not
reporting for 42 U.S.C 1395y(b)(8) is required for these situations is
whether or not the payment is to the injured claimant/representative of the
injured claimant vs. payment to the self-insured entity to reimburse the selfinsured entity. Where payment is being made to reimburse the self-insured
entity, the self-insured entity is the RRE for purposes a settlement,
judgment, award, or other payment to or on behalf of the injured party and
no reporting is required by the insurer reimbursing the self-insured entity.”
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Deductibles
• Where the self-insurance in question is a deductible, and the insurer is
responsible for Section 111 reporting with respect to the policy, it is
responsible for reporting both the deductible and any amount in excess of
the deductible.
– The total of both the deductible and any amount in excess of the
deductible should be reported.
• If an insured entity engages in a business, trade, or profession and acts
without recourse to its insurance, it is responsible for Section 111 reporting
with respect to those actions.
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Reporting in the Corporate Structure
An entity may not register as a RRE for a sibling in its corporate structure.
An entity may register as a RRE for any direct subsidiary in its corporate
structure.
A parent entity may register as a RRE for any subsidiary in its corporate
structure regardless of whether or not the parent would otherwise qualify as
a RRE.
For reporting purposes, a captive is considered a subsidiary of a parent
entity and a sibling of any other subsidiary.
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Which Claims Must be Reported
• Any claim involving Medicare beneficiaries in which
medicals are claimed and/or released in a settlement,
judgment, award, or other payment resolving (or
partially resolving) the claim.
– Subject to timelines, exceptions, and lookback
provisions.
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ORM
• Claims with Ongoing Responsibility for Medical
Payments (ORM) must be reported.
– RRE either accepted responsibility but hasn’t yet
made a payment.
– RRE has made at lease one payment to the
claimant or on behalf of the claimant.
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Total Payment Obligation to the Claimant
(TPOC)
• Defined as a one-time payment, as in a settlement, judgment,
award, or other payment as intended to resolve/partially
resolve a claim.
• Typically applicable in liability cases
– Liability insurance (including self-insurance) claim reports
where the TPOC date is prior to October 1, 2011 with no
ORM involvement do not have to be reported.
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Redundancy
• On claims with multiple defendants, ALL RRE’s involved in a
settlement remain responsible to also report the claim to
Medicare.
• Records must be submitted on beneficiary by beneficiary
basis, by type of insurance, by policy number, by RRE, etc.
Therefore, an RRE may submit more than one record for a
particular individual in a particular quarter’s submission
window.
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Date of Incident
• In workers’ comp., the date of incident does not matter. If a
claim is pending on or after January 1, 2010, it must be
reported if appropriate.
• In liability context, if the date of incident is prior to December
5, 1980, reporting is not required on such claims even if such
claim is settled on or after October 1, 2011.
– For exposure claims, if any exposure was subsequent to
December 5, 1980, claim must be reported if not settled
prior to October 1, 2011.
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Interim Reporting Thresholds
• For no-fault insurance there is no de minimus dollar threshold.
• For liability insurance there is no de minimus dollar threshold for reporting
claims with ORM.
• For workers’ compensation file submissions, only claims with ORM which
meet all of the following are excluded from reporting:
– Medicals only
– Lost time of no more than seven calendar days
– All payments made directly to the provider
– Total payment does not exceed $750.00
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Mandatory Thresholds for Workers’ Compensation
TPOC’s
Total TPOC TPOC Date
On or After
Amount
Reporting Required
in the Quarter
Beginning
TPOC’s over
$5,000
October 1, 2010
January 1, 2011
TPOC’s over
$2,000
October 1, 2013
January 1, 2014
TPOC’s over
$300
October 1, 2014
January 1, 2015
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Mandatory Thresholds for Liability TPOC’s
Total TPOC Amount
TPOC Date On or After Reporting Required in the Quarter
Beginning
TPOC’s over $25,000
July 1, 2012
October 1,2012
TPOC’s over $5,000
October 1, 2012
January 1, 2013
TPOC’s over $2,000
October 1, 2013
January 1, 2014
TPOC’s over $300
October 1, 2014
January 1, 2015
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Claims That DO NOT Have To Be Reported
• Claims in which:
– A judgment or defense verdict is rendered concluding that no money is
owed.
– No claim was made for medical expenses, i.e., liability case with
property damage on with no release of medicals.
• Be careful with general releases!
– There is no settlement, judgment, award, or other payment (including
assumption of ORM).
– The only payment was a onetime payment for a defense evaluation
from a provider or physician.
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Direct Data Entry (DDE)
• DDE option will be available to RRE’s who will only
submit 500 or fewer claims per year.
• RRE’s must register to utilize the DDE option.
• Claim records will be submitted one report at a time.
• Separate query function will not be offered.
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Query Function
• A RRE or its Agent my “query” Medicare once a
month, per RRE ID, to determine whether individuals
are current Medicare beneficiaries.
• Must provide name, social security number, date of
birth, and gender.
• CMS will send a response file indicating if the data
provided matched a Medicare beneficiary.
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Beneficiary Lookup
• Users of the Section 111 COB website can submit
online requests, in addition to query file submissions,
to find out if the individual can be matched to a
Medicare beneficiary.
• Beneficiary Lookup is not available to RRE’s using
the DDE submission method.
• Limited to 100 requests per month, per RRE ID.
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Penalties for Failure to Comply
• Plans failing to provide notification to
Medicare are subject to civil penalty of
$1,000.00 per day, per claimant.
• There are no safe harbors. All plans are
expected to comply.
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• Notification Requirements will ensure Medicare does
not pay when another entity is, even arguably,
responsible.
• Will also enable Medicare to more easily recover
conditional payments from primary payers.
• Expected to save Medicare over $1 billion between
2010 and 2017.
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CMS Memo 2/24/2010
• In general, a Section 111 NGHP RRE will be compliant with
its Section 111 reporting requirements if it registers for
reporting, and once registered, the RRE engages in data
exchange testing, and once testing is completed the RRE
begins and continues with regular Section 111 production data
exchanges. The RRE will then be participating in the Section
111 process in the manner prescribed by CMS.
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• The User Guide revised July 3, 2012 contains
important information regarding Section 111.
• Additional information can also be found at
Medicare’s Reporting website:
– http://www.cms.hhs.gov/MandatoryInsRep/
• Specific Questions may be emailed to CMS at
– PL10-173SEC111-comments@cms.hhs.gov
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Questions?
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Bennett L. Pugh
Franco Signor
1618 Montgomery Hwy. Suite 104 #278
(205) 901-1116
ben.pugh@francosignor.com
Franco Signor
Medicare IVIG Access & Strengthening
Medicare & Repaying Taxpayer Act of
2012
• Became law on 1/10/13
• Access to Intravenous Immune Globuline
• Contains 5 Sections that deal with Medicare
Compliance
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Section 201: Conditional Payment
Information
• Effective 9 months after passed into law.
• This is the deadline for CMS to adopt final
regulations to implement
• Allows parties to obtain CPC information before
settlement in a timely manner
• Applies to WC and GL claims
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Demand Letter
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Parties may request a demand letter from Medicare that is good for a
period of time before settlement
Requires CMS to be provided notice within 120 days of an expected or
reasonably expected date of settlement
CMS has 65 days to provide demand letter but can extend it another 30
days
After appropriate period has elapsed, parties can retrieve CPC info from
website and relay on it
Settlement must occur within 120 days of notice and 3 days from
download from website
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Jurisdiction
• If elected, the Secretaries determination is final
• If procedure not followed, default to previous method
• Right of appeal provided to primary payer but not
Medicare. Beneficiary must be given notice.
• Federal jurisdiction created
• No impact on MSAs
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Section 202 Reporting Thresholds
• Effective 1/1/14
• Applies only to liability claims (expected recovery is less than
cost to recover)
• Excludes ingestion, implantation and exposure cases
• Annual threshold calculated by Secretary of HHS published by
11/15
• No obligation to repay Medicare or report if claim falls below
annual threshold.
• CMS is to report to Congress on thresholds for WC and No
Fault
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Section 203: Reporting Under Section 111
• Effective 1/10/13
• Amended to provide “up to” $1,000 per day per claim, giving
Medicare discretion
• Requires Medicare to solicit proposals for safe harbor
situations within 60 days
• Requires Medicare to propose final safe harbors for good faith
efforts when beneficiary cannot be determined
• No deadline for final safe harbor proposals
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Section 204: Use of SSN in Reporting
• Effective 18 months after enactment
• Secretary can request a one year extension on
application to Congress
• Allows RRE’s to report without using the SSN or
HCIN
• Mitigates against potential state law privacy claims
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Section 205: Statute of Limitations
• Effective 6 months after enactment
• Creates a 3 year statute of limitations on CPC and
Section 111 reporting from settlement, judgment,
award or other payment
• To trigger the protection, the claim must be
electronically reported