Recap of CMS’ April 15 Webinar – TPOC Reporting of WCMSAs

by J. Shymanski

On Wednesday, April 15, the Centers for Medicare & Medicaid Services (CMS) held the latest in a series of webinars on Section 111 Mandatory Insurer Reporting. This webinar focused on the Workers’ Compensation Medicare Set-Aside (WCMSA) information that was added to Total Payment Obligation to Claimant (TPOC) reporting in April of 2025.

A copy of the slides can be downloaded from the What’s New page of Mandatory Insurer Reporting (NGHP) section of cms.gov.

CMS provided background on the authorization for them to require the additional WCMSA reporting fields. CMS went on to explain that historically, they have received incomplete or limited information on WCMSAs which is what prompted them to expand TPOC reporting to include the additional data fields and help ensure that Medicare pays claims appropriately.

CMS then reviewed the WCMSA data fields and walked attendees through their definitions:

CMS continued the webinar with several reporting examples by identifying a situation and walking through the proper WCMSA reporting process for that situation. CMS then addressed what they referred to as several common “reporting issues”:

Section 111 MSA Values Do Not Match Voluntary Process Values
Previously, if the WCMSA amount did not match the CMS determination issued on the file exactly, CMS converted the case to a “non-approved” status – meaning it was no longer a CMS approved case. CMS has since adjusted their system logic to include cents and to contain an amount tolerance so that exact matching is no longer required.

IMPAXX commentary: This is welcome news as it accounts for keying/typing errors on the part of the submitter/reporter. However, we strongly recommend that submitters/reporters have a quality process in place to review all aspects of quarterly reporting.

Professional Administrator EIN
Regarding the two optional fields (Case Control Number and Professional Administrator EIN number). CMS indicated that while they are listed in the NGHP User Guide as ‘optional’, they are only optional to the extent that if the WCMSA did not go through the CMS submission process, a number would not have been assigned. Likewise, if there is not a professional administrator for the case, there would not be a tax identification number to add. However, CMS made it clear that if the data exists, these fields are no longer optional and must be completed. If the CCN is not provided, it could cause multiple cases to be established in the CMS system – causing confusion post settlement. Similarly, if the professional administrator ID is not provided, the administrator could be removed from the CMS record – again, causing confusion post settlement.

IMPAXX commentary: It is good to get clarification on the CMS definition of “optional” on these fields as it was not clear when these fields were originally rolled out in 2025. Reporters should now adjust their internal guidance to ensure that these items (when appliable) are completed as part of the regular course of WCMSA TPOC reporting.

Settlements With Multiple Dates of Incident
CMS reiterated the process outlined in the NGHP User Guide for submitting TPOC where multiple are claims resolved with one settlement agreement. Only one TPOC and one WCMSA should be reported. Reporting should be submitted under the earliest date of injury with all of diagnosis codes from the later injuries included   with the original date of injury. Then the later injuries will only terminate the Ongoing Responsibility for Medicals (ORM).

IMPAXX commentary: This continues to be a frustration for reporters. Not all claim systems are capable of this type of ‘nesting’. Adding newer injuries to an older claim may also complicate state reporting and hinder internal data analytics, which can complicate the conditional payment process, causing issues for all parties post settlement. As a result, parties need to be aware of their reporting constraints when organizing settlements with multiple claims and confirm that settlement document(s) are clear on the specifics of the conditions being resolved.

Voluntary WCMSA Case Removed from the Review Process
CMS confirmed that if a report of TPOC with an WCMSA is received, they will presume that the settlement was finalized and will stop any review process that was in progress.

IMPAXX commentary: Reporters need to be certain that settlement reporting is not done prematurely on any cases to avoid CMS stopping the determination process on voluntarily submitted WCMSA cases. Training that includes the proper process and implications of both premature TPOC reporting (cessation of the CMS review process) and late reporting (potential Civil Money Penalties) is an essential part of Section 111 compliance.

CMS completed the prepared section of the webinar by referencing the sources of information available to assist with the Section 111 reporting process including the NGHP User Guide and the email inbox that they created specifically for reporting questions ([email protected]). The webinar then concluded with a short Question and Answer section, mostly pertaining to basic Section 111 concepts or clarification regarding materials covered in the webinar.

While it is helpful for CMS to continue to host these webinars, frustrations regarding some key aspects of reporting requirements remain – most notably those related to reporting multiple claims. The IMPAXX team will continue to advocate for clarifications and updates from CMS as appropriate and keep you informed of any new guidance or commentary from CMS we may learn through various industry channels.

Please don’t hesitate to reach out to our Settlement Consultant team at [email protected] with any questions you may have regarding the April 15 webinar or any Section 111 Reporting issues.