Medicare Issues Alert on Workers Comp MSA Reporting

Shawn Deane
General Counsel & Vice President of Claims Solutions | J29
Shawn.Deane@j29inc.com 

On February 23, 2024, the Centers for Medicare & Medicaid Services (“CMS”) issued a technical alert associated with forthcoming obligations around reporting Medicare Set Aside (“MSA”) information associated with workers’ compensation settlements. The alert can be found here.

As previously reported in www.workerscompensation.com, CMS held a webinar on November 13, 2023, where the agency outlined expanding Sec. 111 Mandatory Insurer Reporting to capture information in workers’ compensation settlements that include an MSA. In the parlance of Sec. 111, settlements are referred to as a Total Payment Obligation to Claimant (“TPOC”).

It is important to reiterate several key points regarding these upcoming requirements:

• Reporting MSA information will only be applicable to workers’ compensation settlements (not related to other insurance types)
• Will be required regardless of whether the associated MSA was submitted to CMS
• The change will be prospective: for workers’ compensation settlements with MSAs “submitted on a production file with a TPOC date on or after April 4, 2024.” See alert.

In order to collect MSA information, additional fields will be added to the Claim Input File layout. “The Claim Input File is the data set transmitted from… [an insurance carrier or self-insured] to… [Medicare]…” See Sec. 111 User Guide, Chapter IV, at 6.1. Testing for the new fields will be made available for Responsible Reporting Entities (“RREs”, i.e., insurance carriers or self-insureds) beginning on October 7, 2024. CMS also indicated in their alert that, “records submitted on a test file with a TPOC date on or after October 7, 2024, will be subject to the new edits in the test environment.”

CMS further stated that the information in the alert, along with additional information, would be incorporated into a forthcoming April 2024 version of the Sec. 111 User Guide.

In the November 2023 webinar, CMS outlined the new required fields and further articulated them in the alert. A truncated explanation of the fields are below and a full description, with technical details, can be found in the alert.  

CMS indicated that while there will be additional fields in the Claim Input File layout, there will be no change to the Claim Response File layout. “The Claim Response File is the dataset transmitted from [Medicare] to the RRE after the information supplied in the RRE’s Claim Input File has been processed…” Errors relating to the new MSA data will be returned as new “CW” errors on the Claim Response File. Please refer to the alert for a complete listing and description of errors.

As CMS promised in their November 2023 webinar, the agency is moving towards 2025 for implementing these new Sec. 111 reporting requirements for workers’ compensation settlements involving MSAs. On this topic, CMS has previously requested stakeholder feedback to be directed towards:  S111WCMSA@CMS.hhs.gov.

It’s also important to look beyond the technical aspects here and understand CMS will be requiring this data to ensure proper coordination of benefits post-settlement. Therefore, MSA allocation accuracy and proper post-settlement administration will be more critical than ever. Further, it’s imperative primary payers / RREs have a partner to guide them through these upcoming changes, especially with the backdrop of post-settlement risk and the recent finalization of the rule surrounding imposition of civil money penalties in Sec. 111 non-compliance.

J29’s Medicare compliance team will be following these developments closely. Please reach out to Shawn Deane at Shawn.Deane@j29inc.com / (866) 529-6771, with any questions.

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Author Bio

Shawn Deane
General Counsel & Vice President of Claims Solutions | J29
Shawn.Deane@j29inc.com   

(866) 529-6771

www.j29inc.com

As General Counsel & Vice President of Claims Solutions, Shawn Deane leads J29’s legal and Medicare Secondary Payer (MSP) services team. Shawn is a practicing attorney and has over 16 years of experience in Medicare compliance, workers’ compensation, and insurance claims. He was previously General Counsel & Senior Vice President of Risk Management & Compliance at the nation’s largest professional administrator of Medicare Set Asides. Prior to that he was Vice President of Medicare Compliance & Policy at one of the country’s largest Medicare Set Aside vendors. He’s an industry expert and thought leader in workers’ compensation, Medicare Set Asides (MSAs) and Medicare compliance.

About J29

J29 is a women-owned business that offers Medicare Secondary Payer (MSP) compliance services providing Medicare Set Asides (MSAs), conditional payment / lien services and related solutions to all workers’ compensation stakeholders – including carriers, self-insureds, third-party administrators, and attorneys.

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