Section 111: Navigating the Forest, Seeing the Trees

By Daniel Lindner May 19, 2015

Last month, I introduced a new Section 111 Medicare reporting series. We began with purposes and processes to demystify Section 111 at a high level. At its core, Section 111 represents a way for Medicare to collect claim information on Medicare beneficiaries. The questions now revolve around what type of information is required to be reported and when must it be reported.

Medicare determines the form and manner of reporting. Now Medicare’s User Guide has grown to several hundred pages of instructions, making the policies a dense forest of regulations.

Although Medicare isn’t always clear about Section 111, what clarity does exist starts in the User Guide. This guide forms the basis for developing Medicare-compliant claims-handling processes and provides a road map for reporting data to Medicare. Used properly, it provides a clearing between the trees and a path to compliance.

But Section 111 reporting is more than just exchanging data. Last month, we explained in detail that Medicare uses Section 111 data to coordinate benefits (that is, prevent mistaken payment) and recover conditional payments from primary payers. With that in mind, the relationship of the cause and effect of Section 111 reporting becomes clearer.

A programmatic approach allows a claims organization to achieve successful Medicare compliance over an entire line of business. When looking at your compliance practice and protocol ask: How do we get this advantage? How do we implement a compliance program that helps us control loss costs? How do we navigate the right path? Finding your way through the forest of regulations requires a map to know which trees to walk around to reach your destination safely. By taking control of Medicare issues at the early stage of a claim — on every claim — you are headed in the right direction.


Daniel Lindner

Daniel C. Lindner is the director of Section 111 strategy for ISO Claims Partners. Dan joined the company as an MSP compliance manager, leading an ISO Claims Partners’ Medicare conditional payment investigation and negotiation team. Dan is a graduate of New England School of Law and a member of the Massachusetts Bar. Dan can be reached directly at 978-825-8152 or dlindner@iso.com.