In a recent technical alert issued on February 23, 2024, for Section 111 Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs), the Centers for Medicare & Medicaid Services (CMS) announced a significant expansion to the Total Payment Obligation to Claimant (TPOC) reporting process for Workers' Compensation claims involving Medicare beneficiaries. On every settlement (whether a Medicare Set Aside is formally submitted or not via CMS' voluntary review/approval process), CMS now requires submission of the amount of future medical care set aside to protect Medicare’s interest. This decision follows a discussion held at a webinar on November 13, 2023. Effective April 4, 2025, CMS will broaden its data collection efforts via Section 111 to include Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) when claims are settled, marking a pivotal shift in Medicare Secondary Payer (MSP) Mandatory Reporting Provisions.
What's Changing?
CMS will now require the submission of certain WCMSA data fields when claims are settled involving a Medicare beneficiary. This expansion aims to ensure Medicare can collect important information needed for appropriate coordination of benefits, as mandated under 42 U.S.C. 1395y(b)(8)(ii). The data collected will assist Medicare in making informed determinations regarding the coordination of benefits, ensuring that Medicare does not become the primary payer for future medical services related to workers’ compensation injuries.
Key Points to Note
- Prospective Change: The expansion will be prospective, with records submitted on or after April 4, 2025, subject to the new reporting requirements.
- Voluntary Testing: Responsible Reporting Entities (RREs) can voluntarily test the new WCMSA fields beginning October 7, 2024, by coordinating with their Electronic Data Interchange (EDI) representative.
- Enhanced Insight for Coordination of Benefits: CMS' expanded data collection efforts will provide greater insight into non-submitted medical allocations for injured workers receiving Medicare benefits, thus improving coordination and compliance within the Workers’ Compensation system.
- New MSA Fields: The new fields to be collected include: MSA Amount, MSA Period, Lump Sum or Structured/Annuity Payout Indicator, Initial Deposit Amount, Anniversary (Annual) Deposit Amount, Case Control Number, and Professional Administrator EIN.
Impact on Medical Billing
Following the implementation of these changes, the Medicare Administrative Contractor (MAC) will play a crucial role in reviewing medical bills submitted by providers. If a code “W” indicating a WCMSA is present in the Common Working File (CWF), the MAC will deny the bill, as the MSA funds are considered primary.
Simplifying Healthcare Post-Settlement
Given the adjustments to the Total Payment Obligation to Claimant (TPOC) reporting process for WCMSAs, Ametros plays a critical role in aiding settlement stakeholders with Medicare Set Asides. This involves simplifying healthcare with best-in-class professional administration of WCMSAs post-settlement for injured individuals, ensuring compliance with mandatory requirements. While previously some may have thought CMS had limited visibility into non-submitted MSAs, now the visibility will be on par with submitted MSAs and thereby the urgency for proper administration of the funds is even higher.
By providing expert professional administration of medical funds post-settlement, Ametros aims to alleviate administrative burdens and prevent Medicare Set Aside reporting mistakes that can arise post-settlement. Ultimately, this ensures smooth transition of care for injured individuals.
Conclusion
The expansion of Workers' Compensation Section 111 reporting represents a significant step towards improving the coordination of benefits and ensuring compliance with MSP Mandatory Reporting Provisions. By collecting essential WCMSA data fields, CMS aims to protect the integrity of the Medicare program while providing clarity and transparency for all stakeholders involved in Workers’ Compensation claims settlements.
If you have any questions regarding CMS’ recent update, please feel free to contact us at 877-983-9564 or email us at marketing@ametros.com.
