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Mid-Year “Round-Up” 2023 – keeping track of Medicare and other claims updates (ICYMI)

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!

Tackling Medicare Treasury Claims – How Verisk’s Services Can Help

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:


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: 


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:


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:


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:


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:


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.


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:


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:


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:


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. 


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:


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:


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:


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:


On Demand - Webinar Recordings

In case you missed it, are links to our recent webinars:


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!

Mark Popolizio, J.D.

Mark Popolizio, J.D., is vice president of MSP compliance, Casualty Solutions at Verisk. You can contact Mark at

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