Over the past year, CMS has tightened the rules around reporting certain non-group health plan (NGHP) claims. These changes impact how Responsible Reporting Entities (RREs) comply with Section 111 of The Medicare, Medicaid and SCHIP Extension Act (MMSEA) and how they notify CMS about settlements pursuant to 42 CFR §411.25.

Specifically, CMS has confirmed that certain claims – particularly those unrelated to physical trauma – may not be reported via the Medicare Secondary Payer Recovery Portal nor to the Special Projects division. The result? Claims that cannot be reported through CMS’ standard process often become logistically and legally harder to resolve. Settlement timelines stretch out and the risk for delays in Medicare recovery increases. So, what changed - and why is it so difficult to report these types of claims?

The Basics of Reporting

RREs must report NGHP claims to CMS for the purpose of coordinating benefits. Most claims (such as workers’ comp, liability, and no-fault) are submitted via a quarterly Section 111 reporting. Meaning, any given RRE has a quarterly date where their claims are transmitted to CMS for reporting.

But not all claims are captured this way, particularly those where Ongoing Responsibility for Medicals (ORM) is not accepted.

As a result, these types of claims must be manually reported to determine if Medicare needs to be reimbursed for conditional payments

Manual Reporting

CMS offers several approved methods for manually reporting NGHP claims. These include the Medicare Secondary Payer Recovery Portal (MSPRP), fax, calling the BCRC, and physical mail. However, manual reporting is more complicated, time-consuming, and prone to errors.

The most efficient of these options is the MSPRP, as it allows reporting of key data easily and reliably. Other methods such as fax, physical mail and calling the BCRC can be hit-or-miss, with longer processing times and limited to no confirmation that CMS received the information.

Special Projects Division

Just to complicate things more, when attempting to report these types of claims in the MSPRP, an automated response specifies the claim should be mailed or faxed to “Special Projects” for review. Historically, the Special Projects department within the BCRC would review non-physical trauma cases to develop for reporting purposes. Yet, as of October 2023, Special Projects ended review of all non-physical trauma claims and is now designated for reporting only “product related injuries” for exposure, ingestion, implants, or inhalation. As such, countless claims are being blocked from reporting via the MSPRP or Special Projects. These claims include (but are not limited to):

• Non-physical trauma workers’ compensation claims
• Psychiatric conditions
• Cancer
• Sexual abuse claims
• Federal black lung cases
• Malpractice
• Neglect

Herein lies the problem: Reporting these claims through the MSPRP results in an error message directing the claim to be reported to Special Projects. Even more confusing, the Special Projects department ended its practice of reviewing these claims. For parties that are trying, in good faith, to settle these claims and consider Medicare’s interest with regard to conditional payments, this drawn-out process is less than ideal.

Conclusion

It is unclear whether CMS plans to expand reporting options for non-physical trauma-based claims. For now, the only workaround appears to be manual reporting via fax, mail, or phone, all of which are slow, unreliable, and frustratingly inconsistent.

If CMS continues to block these claims from being reported via the MSPRP or Special Projects, the current manual methods need serious improvement. Delays of weeks or even months are common, and that is not sustainable for claims already on a tight settlement timeline. Unless CMS streamlines this procedure, it is possible RREs will abandon the conditional payment verification process if the difficulty in reporting begins to derail settlements.

Final Thoughts

RREs still have a responsibility to timely report claims and to consider Medicare’s interest when it comes to conditional payments – even if CMS’ current processes make it difficult to do so. While CMS does offer escalation paths and has coordinators who are very helpful, that does not change the fact that there is no consistent, predictable path forward for these types of claims.

If you are dealing with a non-physical trauma-based claim, don’t wait. Manual reporting takes time, and the earlier you start, the more likely you are to avoid delays. As CMS’ policies evolve, ECS is here to support our clients with the knowledge and tools needed to confidently manage even the most complex reporting scenarios.

ECS and our expert MSA team is available to assist you with your Section 111 reporting and conditional payment needs. We will continue to keep readers apprised of further agency developments from CMS as we monitor this and all areas of MSP compliance closely. ECS MSA clients should address any questions to mspcompliance@examworkscompliance.com. Should you have any questions on these developments please contact Michael Flower at 678-222-5485 or Michael.Flower@ExamWorksCompliance.com.