What Do Medicare and Charlie Brown Have in Common?

February 19, 2023

Lucy and Charlie Brown. The Cleveland Indians. Peter O’Toole. The Minnesota Vikings[1]. CMS and Medicare Secondary Payer regulations. If you got “Famous Almosts” you just won the $25,000 Pyramid.

No, Dick Clark or Michael Strahan isn’t here to greet you with a big check but you do have another year to wait for Section 111 civil money penalty regulations.

In perhaps the least surprising but most suspenseful Medicare compliance news of 2023, Medicare released a notice Friday night that it was announcing a “1-year extension of the timeline for publication of the final [Section 111 civil money penalties] rule.” As faithful readers of ECS on MSP will recall, CMS officially released the proposed rule on Section 111 civil money penalties on February 18, 2020. With the announced delay, CMS is delaying the publication of the final rule because “it is critical to conduct additional analysis about the economic impact of the rule.”

 The Proposed Rule

 The proposed rule focuses on three concepts where responsible reporting entities (RREs) could be subject to civil penalties: outright failure – a complete inability to report required information; contradiction – a report that is later contradicted by a conditional payment dispute or appeal; and poor quality – a failure to adhere to minimum standards of data quality in reporting. At the time of the proposal, ECS provided a written comment illustrating several shortcomings in the proposal – notably around the concept of contradiction.

 The Delay

 CMS chose to delay publication of a final rule by one year, until February 18, 2024, in order to perform analysis on the economic impact of the proposal. While the proposal – which has the potential to assess catastrophic financial penalties to recalcitrant RREs – is not classified as “economically significant” by CMS, the agency acknowledged that it was “not able to meet the initial targeted 3-year timeline for publication due to delays related to the need for additional, time-consuming data analysis resulting from public inquiry.” Specifically, “public listening sessions raised additional concerns that CMS believed were important to properly and thoroughly research prior to publishing the final rule.” Finally, CMS explained that “We are extending the publication deadline so as to provide the most accurate, complete, and robust data possible to confirm the intent and economic impact of the final rule.”

 What’s Next?

 We wait. Section 111 civil money penalty regulations are coming, it’s just a matter of when. Unlike Charlie Brown and Peter O’Toole, at some point CMS is going to kick the football or win the Academy Award and issue these final rules. It is our sincere hope and request that the agency takes an exceedingly careful evaluation of the scope of all aspects of Section 111 reporting – including not only the penalties but the claims-system modifications, over-indulgent conditional payment demands, and improperly denied treatments to truly assess the economic impact of the potential final rule.

 ECS’ Compliance and Mandatory Insurer Reporting Teams will continue to closely monitor for additional information. For now, as always, we recommend that RREs report Section 111 data Accurately, Completely, and Timely – ACT for short. If your organization has any questions about Section 111 reporting or would like to learn more about ECS’ Award-Winning MIR Service reporting platform, please contact us at mirservice.support@examworkscompliance.com.


[1] This reference was authorized by Annie M. Davidson.

Marty Cassavoy

Marty Cassavoy

Marty Cassavoy is the Sr. Vice President of MSP Compliance and Business Development at ExamWorks Compliance Solutions. Marty and his team develop solutions for challenges in all areas of Medicare Secondary Payer compliance and across all insurance types. An attorney licensed to practice law in Massachusetts, Marty works out of ExamWorks’ Woburn, Massachusetts office and can be reached at 781-517-8085 or martin.cassavoy@ExamWorksCompliance.com