Hard to believe but we are at the mid-point for 2023! It has been a busy year in so many claims areas. As such, it may be a good time to regroup on the key claims updates over the past several months – ICYMI style!
To help keep track of the moving targets, the below serves as a “mid-year roundup” highlighting the key updates thus far in 2023 – topics include: Section 111 reporting, Medicare set-asides, Treasury claims, Medicare Advantage, FROI/SROI, Third-Party Litigation Funding, webinar recording links, and more! Plus, we have included information on our Discovery Navigator tool which continues to generate much industry excitement! In terms of the format, each topic has a short summary which is then followed by links to our related articles, and as applicable, links to Verisk services!
Scroll down and find your topic(s) of interest!
Section 111 – CMS’s civil money penalty “final rule” is pushed back
No doubt many NGHP RREs likely breathed a sigh of relief when CMS announced in February that it was pushing back its timeline to release the Section 111 civil money penalties (CMP) "final rule” until February 18, 2024. In delaying release, CMS cited the need to further study the “economic impact” of its CMPs proposals. The below resources provide the details:
Resources:
- CMS pushes back the timeline to release its Section 111 penalties “final rule” for one-year (until February 18, 2024)
- Section 111 penalties level-set: FAQs, updates, and what’s next
Section 111 - NGHP Unsolicited Response File “opt-in” (starts July 2023)
In a major Section 111 development, CMS announced its Section 111 NGHP Unsolicited Response File “opt-in” process starting in July 2023. Very generally, through this process RREs will be able to “opt-in,” via the Section 111 Coordination of Benefits Secure Website (COBSW) application, to receive a monthly NGHP Unsolicited Response File, regarding updates made to the ORM record by the beneficiary or their authorized representative. Our article resources below outline this update and key details regarding this process as follows:
Resources:
- Understanding CMS’s Section 111 NGHP Unsolicited Response File “opt-in” process (starts July 2023) – Q&A resource (updated)
- CMS’s Section 111 NGHP Unsolicited Response File “opt-in” process - Nutshell Summary Resource
- CMS holds webinar to discuss the Section 111 Non-Group Health Plan (NGHP) Unsolicited Response File “opt-in” feature (starts July 2023) and other Section 111 items
Section 111: ORM trigger, ORM termination, and other updates
As part of User Guide (Version 7.2) updates, CMS has made changes regarding the ORM reporting trigger, ORM termination, and other updates to Section 111 reporting. The below resources outline CMS’s recent activity in these areas:
Resources:
- CMS releases Section 111 NGHP User Guide (Version 7.2, June 5, 2023) – new changes include: NGHP Unsolicited Response File, ORM reporting trigger, ORM termination, and HEW software
- CMS holds webinar to discuss the Section 111 Non-Group Health Plan (NGHP) Unsolicited Response File “opt-in” feature (starts July 2023) and other Section 111 items
Section 111 - Non-Binary and Unspecified General Designations
In May, we released an article on CMS’s Query Process and non-binary/unspecified gender designations which is an issue we are receiving questions about from many NGHP RREs. The below article provides an overview of the issues and current challenges in this area as follows:
Resources
CMS releases NGHP Applicable Plans Appeals Reference Guide
In late April, CMS released a Non-Group Health Plan (NGHP) Applicable Appeals Reference Guide (Version 1.0, April 27, 2023) to provide NGHP plans, and their authorized representatives, with a summary of requirements and guidance to be used when submitting appeals of MSP recovery claims in situations where Medicare is seeking recovery against the insurer. The article below provides the key details related to this development as follows:
Resources:
Medicare Treasury Claims updates
As many will recall, CMS released a report last fall which, in part, reported that Treasury collections jumped from $55 million in 2020 to $82 million in 2021, a 47% increase. Thus, earlier this year we released an update article on CMS Treasury claims to get this issue back on the radar. See the below article resource for more details, along with how our Treasury services can help you address (and reduce) Treasury actions, as follows:
Resources:
- Understanding Medicare Treasury claims – avoiding the pitfalls and steps for success
- Learn how Verisk can help you take the right steps to avoid U.S. Treasury Department collections, including our Treasury Service which offers proactive Treasury monitoring through the Government to Government (G2G) program to help with timely notification of Treasury Debts and Offsets.
Medicare Advantage Plans (“double damages”)
In late February, the United States Court of Appeals for the Second Circuit dismissed a Medicare Advantage “double damages” claim ruling, in main part, that an insurer’s Section 111 reporting did not provide grounds for the claim. A few months later, the United States District Court for Massachusetts, finding the Second Circuit’s ruling persuasive, reached the same conclusion and dismissed a Medicare Advantage “double damages” lawsuit in that case. On another front, the United States Court of Appeals for the Eleventh Circuit dismissed a Medicare Advantage “double damages” action finding, in main part, that the MSP statute did not pre-empt an insurer’s claims filing deadline or Florida’s no-fault pre-suit demand requirement.
Resources:
- The United States District Court for Massachusetts dismisses a Medicare Advantage claim for “double damages” – rules that insurer’s Section 111 reporting does not establish standing to sue
- Second Circuit dismisses Medicare Advantage “double damages” lawsuit on standing grounds – rules the insurer’s Section 111 reporting did not establish liability
- The Eleventh Circuit dismisses a Medicare Advantage “double damages” lawsuit – court rules the MSP statute does not preempt insurer's claims-filing deadline or Florida’s no-fault pre-suit demand
WCMSA - CMS eliminates time limit for WCMSA Amended Review (new change can help reduce WCMSAs)
Some good news was received on the WCMSA front in May as part of CMS’s new WCMSA Reference Guide (Version 3.9). Specifically, as part of the Version 3.9 updates, CMS removed the maximum time limit for eligibility regarding its Amended Review Process. This will now provide parties with additional opportunities to use this process going forward to potentially reduce prior CMS WCMSA counter-higher approvals for qualifying cases. Our article below discusses this important update in greater detail, while our Second Look brochure outlines how we can help you take advantage of CMS’s Amended Review process to reduce WCMSAs as follows:
Resources:
- CMS releases the WCMSA Reference Guide (Version 3.9) – various updates are made, including removing the time limit on Amended Reviews
- Learn how Verisk’s Second Look service can help you optimize CMS’s Amended Review process
WCMSA - general updates
As part of the WCMSA Reference Guide (Version 3.9) updates, CMS provided new information regarding frequency calculations for intrathecal pumps, spinal cord stimulator, and peripheral nerve stimulator replacements regarding WCMSA allocations. In addition, the agency also recently released its annual life table updates. See the below resources for additional information as follows:
Resources:
- CMS releases the WCMSA Reference Guide (Version 3.9) – various updates are made, including removing the time limit on Amended Reviews
- Starting April 29, 2023, CMS Will Use the 2020 CDC Life Table for WCMSAs
What’s up in D.C.?
In May, the Repair Abuses of MSP Payments (RAMP) Act was re-introduced into the U.S. House of Representatives and the U.S. Senate. The RAMP Act proposes to modify the Medicare Secondary Payer (MSP) Act’s private cause of action by eliminating non-group health plans from its application. Our article provides the details as follows:
Resources
FROI/SROI updates
There is also activity of the FROI/SROI front. Louisiana transitioned to Release 3.1 for FROI reporting effective May 22, 2023. Texas will transition to Release 3.1 for FROI and SROI reporting effective July 26, 2023. Looking forward, Idaho and Vermont will transition to release 3.1 as of September 14, 2023 and November 6, 2023, respectively. Our below resources outline these updates regarding Louisiana and Texas - be on the lookout for upcoming articles regarding both Idaho and Vermont transitioning to Release 3.1 in the near future.
Resources:
- Reminder update: Louisiana transitions to Release 3.1 regarding First Report of Injury (FROI) reporting effective May 22, 2023
- Reminder update: Texas transitions to Release 3.1 regarding First Report of Injury (FROI) and Subsequent Report of Injury (SROI) effective July 26, 2023
Detail Claim Information (DCI) sunsets at the end of December 2023
The clock is ticking regarding the sunsetting of the Detail Claim Information (DCI) later this year for all states except Texas. The DCI will be replaced by Indemnity Data Call (IDC). Our resources below provide helpful information regarding this important change as follows:
Resources:
- Changing of the Guard: Detail Claim Information (DCI) is sunsetting and the Indemnity Data Call (IDC) will take over – what you should know
- DCI Sunset “One Pager”
New York – reporting threshold for the Indemnity Data Call and Medical Data Call eliminated
In a major development, earlier this year the New York Compensation Insurance Rating Board announced that it is eliminating the eligibility threshold for reporting the Indemnity Data Call and Medical Data Call All carriers no matter the volume of claims will be required to report these data calls beginning in 2024 or 2025, as more specifically outlined by the Rating Board. Our article below outlines this change and what you need to know to prepare:
Resources:
Discovery Navigator
There continues to be much excitement regarding Verisk’s Discovery Navigator which is our innovative (and popular) tool which helps automate the review and retrieval of key information from medical records through sophisticated AI. The below resources discuss how our Discovery Navigator tool can help you streamline the medical record review process as follows:
Resources:
- Harnessing AI and ML through Discovery Navigator to save time and money on medical records review
- Learn More about Discovery Navigator
Third-Party Litigation Funding (TPLF)
We have seen considerable activity on the TPLF front in 2023. Several proposed TPLF bills were introduced in state legislatures during this year’s state legislative sessions. In early spring, Montana enacted a new TPLF statute regulating various aspects of TPLF practices, with this new law also including a TPLF disclosure provision. Indiana has also enacted a new statute regarding TPLF disclosure. At the federal level, several industry groups recently renewed their calls for the establishment of a federal TPLF disclosure rule as part of the Federal Civil Rules of Procedure. The Highway Accident Fairness Act has been reintroduced into Congress which contains a proposed TPLF disclosure provision. These, and other TPLF updates, are outlined in the following resources:
Resources:
- Governor Edwards vetoes Louisiana’s proposed Third-Party Litigation Funding (TPLF) disclosure bill
- Several industry groups renew calls for a mandatory TPLF disclosure rule as part of the Federal Civil Rules of Procedure
- Indiana enacts statutory provision regarding third-party litigation funding (TPLF) disclosure
- Montana enacts the “Litigation Financing Transparency and Consumer Protection Act” – new law regulates TPLF practices and includes disclosure and discovery provisions
- The Highway Accident Fairness Act of 2023 (H.R. 2936) is introduced into Congress – bill prohibits staged accidents with commercial vehicles and includes TPLF disclosure provisions
- Florida (and other states) take aim at regulating Third-Party Litigation Funding
- TPLF disclosure proposals are introduced in Kansas, Mississippi, and Montana state legislatures
On Demand - Webinar Recordings
In case you missed it, are links to our recent webinars:
- Medicare 2023 Watchlist: Mastering CMS’s Moving Targets in the New Year
- Understanding Medicare Treasury Claims – Avoiding the Pitfalls and Steps for Success
- Tackling Medicare Treasury Claims – How Verisk’s Services Can Help You Stay Compliant and Reduce Costs
- Discovery Navigator: Save Time and Reduce Costs with Revolutionary Medical Record Review
- Verisk’s Pre-MSA and Cost Mitigation Provider Outreach service: take control early to reduce MSA costs and get claims settled
Questions?
We certainly hope you found the above overview and roundup helpful! Of course, let me know if you have any questions regarding the above issues, or how Verisk can help you!
