CMS Hosts April Townhall to Review Section 111 Reporting Updates

Webinar Desktop

by J. Shymanski

NOTE: CMS experienced technical issues during the webinar and attendees were only able to join via the telephone conference line with no ability to ask questions live. CMS released the presentation slides quickly and indicated they would would consider scheduling a separate question and answer session.

CMS began the webinar by recapping the MSP provisions [including 42 USC 1395y(b)(8)(ii)] that authorize them to capture Section 111 reporting data to make appropriate decisions regarding the coordination of a Medicare beneficiary’s benefits. CMS then focused on the new requirement that begins on April 4, 2025 – the reporting of Workers’ Compensation Medicare Set-Aside (WCMSA) amounts as part of the Total Payment Obligation to Claimant (TPOC) reporting for current Medicare beneficiaries.

During the discussion, CMS reiterated the following:

    • WCMSA TPOC information should completed for ALL cases no matter the total dollar amount of the settlement or the dollar amount of the WCMSA.
    • Cases that utilized the voluntary CMS submission and review process AND cases opted out of the voluntary process or that did not meet the threshold for the submission process need to complete WCMSA TPOC reporting.
    • This requirement will be PROSPECTIVE ONLY. Therefore, all TPOCs with a date after April 4, 2025, will need to be reported.
    • Parties using the voluntary CMS submission process will still need to send final settlement documents to CMS and the new reporting requirement does not relieve parties of this obligation. CMS then outlined the fields that will need to be completed for the WCMSA TPOC reporting which include the following:
      • Field 37 – total MSA amount (TPOC without an MSA it would be a zero)
      • Field 38 – the MSA period (required if MSA is greater than zero)
      • Field 39 – S for structured settlement annuity and L for lump sum (required)
      • Field 40 – initial deposit amount (required)
      • Field 41 – anniversary of annual deposit (required if it is a S)
      • Field 42 – case control number. If there was CMS WCMSA submission, there will have been a control number assigned.  It is not a required field but if you have it, they ask that you enter it so they can match it up. (not a required field)
      • Field 43 – professional administrator EIN (not a required field)

CMS then shared the error codes that would be received for these fields:

    • CW01 – Non-numeric data is entered in Field 37 (hard error)
    • CW02 – Non-numeric data in Field 38 (hard error)
    • CW03 – Field 38 is all zeros when Field 37 is greater than 0 (hard error)
    • CW04 – “L” or “S” was not entered when Field 37 is greater than 0 (hard error)
    • CW05 – Non-numeric data in field 40 (hard error)
    • CW06 – Non-numeric data in Field 41 (hard error)
    • CW07 – Field 41 contains zeros when Field 39 is “S” (hard error)
    • CW08 – Wrong/Invalid case control number entered (hard error)
    • CW09 – Field 43 contains an invalid EIN number for professional administrator
    • CW10 – Field 37/MSA amount entered as 0 but data was then entered in Fields 38-41 (hard error)
    • CW11 – Field 37 contains MSA amount but TPOC amount is not given in Field 81
    • CW12 – Lump sum indicate in Field 38 but annuity information was entered

Testing for these new fields will be available to Responsible Reporting Entities (RREs) starting on October 7, 2024. RREs were instructed to contact their EDI representatives to coordinate the process.

CMS noted that although failing to report this information may not give rise to Civil Money Penalties (CMPs), errors that occur as a result of this reporting could prevent CMS from reviewing TPOC and result in untimely reporting. CMS also noted that they can utilize other statutory remedies including the False Claims Act for failing to report WCMSA information.

CMS also reviewed other information regarding CMPs:

    • As previously stated by CMS, any new requirement regarding CMPs would not be imposed for two quarters after the new requirement goes into effect. Since the requirement is effective April 4, 2025, no records that involve this new WCMSA TPOC requirement would be eligible for CMPs until October 4, 2025
    • The TPOC reporting threshold will stay the same at $750.
    • The CMS review threshold for voluntary submission for a Medicare beneficiary will remain at $25,000.
    • RREs that settle jointly on the same settlement documents will still each need to report the whole settlement and each report the whole WCMSA TPOC amount.

Expanding TPOC to include the additional WCMSA information will require technical updates to current systems and processes. It is also an opportunity to review your current procedures for protecting Medicare’s interest in all cases regardless of CMS review thresholds. As noted by CMS on this call, settling claims below threshold does not relieve parties from their Medicare obligations. Below threshold allocations should be considered when resolving claims where future medical will be required. In addition, CMS noted again and again during this call that submission of an WCMSA is a voluntary process and not required under the law. What is required is a reasonable consideration of Medicare’s interest. A certified or non-submit MSA is one way to ensure that burden of paying for injury-related future medical does not shift to CMS.

If you have questions regarding what was covered during the townhall webinar, or would like to discuss your Medicare compliance needs, please contact the IMPAXX Settlement Consulting team at [email protected]