Avoid Surprise Conditional Payment Claims with Section 111 Reporting

I am sure we can all agree that unexpected Medicare conditional payment claims are not the holiday surprise anyone wants! As we recently discussed here, CMS has increased the amount of lien correspondence it has been sending out recently. To avoid surprising correspondence on closed files and streamline the resolution process, it is important to keep a close eye on Section 111 reporting. There are a few main Section 111 reporting issues that we see most often when assisting with the resolution of Medicare conditional payment claims.

1. Termination of Ongoing Responsibility for Medicals Has Not Been Reported

CMS will continue to research conditional payment claims until they are notified of settlement and/or Termination of Ongoing Responsibility for Medicals (ORM) via Section 111 reporting. Sometimes, however, claim settlement or claim closure based on state law does not translate to a Section 111 reporting update. This can lead to a “surprise” assertion of conditional payment claims from CMS years after the claim has closed! Even if the charges asserted are for treatment long after closure of the claim, it is necessary to dispute the charges through Medicare’s administrative review process, requiring that your file be reopened for a matter you thought was long resolved.

2. The Diagnosis Codes Reported Do Not Match the Claimant’s Injuries

The injuries associated with the date of loss should be reported fully to CMS. However, sometimes diagnosis codes are reported to CMS that are totally unrelated to the injury suffered. This may result in CMS asserting conditional payment claims unrelated to the injury at issue but related to the incorrectly reported diagnosis code. In addition to a Section 111 correction, disputing these charges almost always requires providing CMS with treatment records clarifying the related injury. This can present a problem if there is not a wealth of documentation on the injury.

3. The Incorrect Party Is Listed as the Debtor

On occasion the TPA or another incorrect entity is reported as the primary payer in the file rather than the insurer or self-insured party. This can make it difficult to obtain authorization to dispute and resolve conditional payment claims. This issue is also commonly seen when a claim is transferred from one insurer to the other. Primary payor information should be updated via Section 111 reporting as part of the transfer of the claim.

4. ORM Is Reported Unnecessarily

Last, but certainly not least, sometimes ORM is reported for denied claims. When a denied claim settles, a Total Payment Obligation to Claimant (TPOC) report should be made where required under the Medicare Secondary Payer Act. However, an ORM report generally would not be needed.

Section 111 reporting issues can be confusing, but ensuring that reporting is done in a timely manner and as accurately as possible can save many future headaches. If you have any questions about whether certain events should prompt an update in Section 111 reporting, please do not hesitate to reach out to us. Also, if things have gone wrong and Medicare is asserting charges in what you had listed as a closed file, please let us know. We are here to help!