CMS Final Rule and Section 111 Noncompliance

January 31, 2024 at 1:00pm2:30pm (PDT)

Catherine Goldhaber is presenting a webinar hosted by Strafford titled: "CMS Final Rule and Section 111 Noncompliance: Reporting Obligations; Audit Methodology; Costly CMPs; Safe Harbor."


The recently released CMP Rule, "Medicare Secondary Payer and Certain Civil Money Penalties," describes CMS' audit methodology, discusses how and when CMPs are imposed, and establishes CMP amounts and methods for calculation. The final rule also provides safe harbor provisions, describes governing time periods, and addresses the notice and appeals process.

The panel will discuss under what circumstances CMS may impose CMPs on responsible reporting entities (RREs) who do not comply with Section 111 reporting obligations, as well as how CMPs are calculated. This discussion will include potential exceptions to Section 111 reporting, CMS audit methodology, safe harbor provisions, and best practices for compliance. The panelists will also address potential risks to Medicare beneficiaries who fail to communicate with Medicare in regard to reported claims.

Pursuant to the MSPA, Medicare is the secondary payer in all cases where another payer, either a group health plan (GHP) or non-group health plan (NGHP) (collectively, RREs), has responsibility for a Medicare beneficiary's medical bills. GHPs who provide medical insurance to beneficiaries are required to Section 111 report coverage to assist Medicare with coordination of benefits. NGHPs have two separate and distinct reporting obligations: (1) where the NGHP assumes ongoing responsibility for medicals (ORM) and the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving treatment), ORM must be reported; and (2) where there is a payment obligation through settlement, judgment, or otherwise to a beneficiary and the beneficiary has alleged and/or released medical expenses, the NGHP must Section 111 report the total payment obligation to claimant (the TPOC).

Other key issues to be covered:

  • How does the final rule differ from the proposed rule?
  • Who are RREs?
  • Under what circumstances are CMPs imposed and how are they calculated?
  • What are the safe harbor provisions described in the final rule?
  • What is the appeal process when CMPs are imposed?
  • What does this mean for plaintiff attorneys?