ExamWorks Clinical Solutions welcomes you to our Chronicle. In these brief articles, we will cover the ins and outs of all things related to Medicare Secondary Payer, MMSEA Section 111 Reporting, and Case Management. Our articles will uncover basic concepts and then move through the many nuances involved, helping you navigate the oftentimes complicated regulations and processes. In addition, our subject matter experts will be addressing and sharing FAQs and lessons learned.
What is MMSEA Section 111 and who is required to report to Medicare/CMS?
MMSEA Section 111 is an acronym for Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007. MMSEA Section 111 Reporting was created to assist Medicare in determining when/if there are other insurance coverages that are primary to Medicare. This federal law requires Insurers or self-insured entities to report specific data elements to CMS when reportable events occur that involve Medicare eligible individuals. CMS’ main goals in gathering this claim data are:
- Coordination of benefits: Ensure that Medicare only pays for medical treatment when there is no other responsible payer who can pay for the beneficiary’s medical treatment.
- Recovery: Obtain reimbursement for the Medicare Trust Fund whenever Medicare makes a payment that should have been covered by another responsible payer.
Section 111 reporting can be complex and requires coordination between claims operations, IT departments and executive leadership. Substantial issues can arise if reporting falls short both internally (in the form of inefficiency and added cost) and externally (in the form of possible civil money penalties of up to $1,000 per day per claim). If your organization is involved with claims involving a medical component, whether directly responsible or not, you may be required to participate in MMSEA Section 111 Reporting. If you have any questions about the reporting process or need assistance determining if you have an obligation to report, please contact us at MIRService.Support@examworks-cs.com.
Stay tuned for the next installment.