April 4th - Solutions for Workers' Compensation and Liability Settlements

Craig Pawley, Vice President of Business Development

20/May/2025

Effective July 1, 2009, the Medicare & Medicaid SCHIP Extension Act (MMSEA) requires that “applicable plans” must first determine whether an injured party (including an individual whose claim is unresolved) is entitled to Medicare benefits. The primary payer must then report the “required information,” once the case is resolved, to the Secretary of the Department of Health and Human Services (Secretary of HHS) in the “form, manner, and frequency” the Secretary prescribes (CMS is a regulatory body under HHS). If this information is not provided to Medicare in the form, manner, and frequency requested, Medicare may impose a fine of up to $1000 per day, per injured party, as Civil Monetary Penalties (CMPs).

Before the MMSEA was enacted, Medicare relied on settling parties to notify it when settling a case for a Medicare beneficiary. This process allowed Medicare to gather some information about the case and look for instances where it had made payments for treatment and RXs where there was a primary payor involved (i.e. Carrier, TPA, Self-Insured, etc). Because this information was not required by law, Medicare put in place a mandatory insurer reporting (MIR) process that requires primary payors to provide over 200 data fields with information about the case and all the parties involved. The collection of that data is then used to place a marker in Medicare’s system. This marker will help Medicare determine if treatment or prescriptions are related to a settlement involving a primary payor. Medicare will then use that marker as a reference point to deny paying for Medicare-covered, case-related treatment. There have been improvements made to the system over the last 16 years, and the number of data fields that must be reported has increased over time.

Fast forward to April 4th, 2025. Medicare now requires that if a MSA allocation was prepared on the case, that information must be entered into the WCMSA field during the reporting process. Medicare expects the MSA amount to be spent on Medicare-covered, case-related treatment per CMS’s guidelines for MSA funds. In the past, Medicare was unaware of the MSA amount if the case was not submitted to CMS for approval. CMS has seen a steady decline in cases being submitted for approval, and essentially had no viewership on the MSA figure, which makes it difficult to know when Medicare would step in and become the primary payor again for Medicare-covered, case-related items. As of April 4th, 2025, Medicare now requires this information to be provided to them for WC settlements, regardless of whether a MSA allocation was submitted to them for approval.

Medicare is now armed with all the information they need, regardless of submission status, to review and deny payments for Medicare-covered, case-related items. This will force the individual to use those MSA funds for Medicare-covered, case-related treatment until they are exhausted. Accurate accounting and annual attestations (post-settlement) must be provided to Medicare before they step in as the primary payor. If the beneficiary fails to provide the necessary information, Medicare will continue to deny payments until proper documentation is provided that shows the WCMSA funds were spent in compliance with Medicare guidelines. If those funds were misappropriated, Medicare will continue to deny payment for any Medicare-covered, case-related treatment and RXs until the funds are replenished and spent according to Medicare’s guidelines.

In 2017, CMS indicated, “Although beneficiaries may act as their own administrators, it is highly recommended that settlement recipients consider the use of a professional administrator for their funds.” Now that the WCMSA field is required as part of the Mandatory Insurer Reporting process, it is critical to discuss the proper administration of the MSA funds during the settlement process.

If you have any questions or would like more information about how Medivest can protect future Medicare benefits for the injured worker, please contact us at info@medivest.com or contact our office at 877-725-2467.

Medivest

01/Apr/2025

Starting April 4, 2025, significant changes are coming to Section 111 reporting requirements for workers’ compensation claims involving Medicare beneficiaries. If you’re a Responsible Reporting Entity (RRE), it’s time to prepare for a broader scope of data reporting, especially when it comes to Workers’ Compensation Medicare Set-Asides (WCMSAs).

Under the new requirements, all workers’ compensation claims involving a Total Payment Obligation to the Claimant (TPOC) must now include WCMSA-related data when the injured party is a Medicare beneficiary. This applies regardless of whether the WCMSA was reviewed or approved by Medicare. CMS has updated reporting requirements published in the NGHP User Guide of the MMSEA Sections 111, which you can view the following chapters below.

Here is a breakdown of what needs to be reported:

1. Medicare-Approved WCMSAs:
  - If your settlement includes a WCMSA that was reviewed and approved by CMS, you must report the relevant WCMSA data.
2. WCMSAs Below the Review Threshold:
  - Even if the WCMSA wasn’t submitted for CMS review because the total settlement amount falls below the Medicare workload review threshold, the WCMSA information still needs to be reported.
3. Zero-Dollar WCMSAs:
  - When a settlement explicitly states that no funds are allocated for future medical care, this is considered a Zero-Dollar WCMSA. These must also be reported.
4. Unsubmitted WCMSAs:
  - If the parties developed an MSA or allocated funds for future medical treatment but chose not to submit it to Medicare, that information must now be disclosed.

What Should You Do Now?

If you’re a claims professional, insurer, or third-party administrator, be prepared to:

- Review your Section 111 reporting processes and confirm they can handle the new data requirements that can be found.
- Coordinate with your WCMSA vendors to ensure you receive the necessary data for inclusion in your reporting.
- Educate your claims team and legal partners about the upcoming changes so all parties are aligned before April 4.

Takeaways

The expanded Section 111 reporting requirements reflect CMS’s ongoing efforts to protect the Medicare Trust Funds. While they may add complexity to the reporting process, these changes also provide an opportunity for claims handlers to strengthen compliance and improve documentation practices.

For Additional Information

As always, Medivest remains committed to assisting our clients with the creation and administration of WCMSAs. Medivest will continue to monitor changes occurring at CMS and will keep our readers up to date when any new changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us at 877.725.2467.

Medivest

26/Aug/2024

It’s been a busy 2024 for CMS. Since February 2024, over half a dozen updates have been made to Section 111 Mandatory Insurance Reporting and CMS’s policies.

Ultimately, these new changes increase awareness and focus on post-settlement MSA spending, emphasizing the importance of utilizing a competent professional administrator.

What this means is you need Medivest’s Asure Pro-Admin more than ever to navigate these changes and keep all settlement parties from getting penalized for non-compliance!

**Medivest’s Asure Pro-Admin Helps Protect All Parties**

Asure Pro-Admin:
Professional Administration for MSA Accounts by the professionals

Medivest claimant accounts saved over 70% of what they were billed by providers over the last 12 months
An average of 23.3% of the original MSA is disbursed to the surviving beneficiary or reversionary interest party upon the claimant’s death
During our 27 years of business, we have only had a 2% member cancellation rate due to unforeseen reasons other than death. This remarkable retention rate underscores the value and satisfaction our members experience with our services
Medivest members and clients can be confident that a Claims specialist will review every line item on every bill submitted, ensuring proper coordination of benefits

Self-Asure:
The DIY solution with Medivest’s expert support

Don’t go it alone! Use Self-Asure to navigate the CMS government maze
The Self-Asure Self-Administration Kit, an innovative tool first created by Medivest, is good for injured parties with a small MSA that is designed to exhaust in a short length of time. Self-Asure provides guidance to individuals who opt to manage their own MSA, and pairs it with phone support and medical bill review from Medivest’s experienced Member Services team.
However, a Self-Administration Kit still has limitations, particularly if multiple bills come in at once. So the settlement parties need to carefully consider Medivest for professional administration per CMS’s recommendation.

4 Asure:
Easy approach to navigate settlement compliance for Insurer, Self-insured, and TPA without adding ANY work to the adjuster’s already full plate. The streamline process of:

Medicare Status check/lien investigation to determine if MSA is recommended
Structured Settlement consultant for rated age and MSA funding
MSA Allocation Report (if needed)
Professional Administration of MSA

CONTACT MEDIVEST TODAY – WE ARE HERE TO HELP!

877-725-2467 (Monday – Friday 8am to 5pm EST)

Summary/Takeaways

MMSEA Section 111 Mandatory Insurer Reporting (NGHP)

Medicare is ramping up its data collection. New fields have been added to the Section 111 Claim Input File to capture WCMSA information on all Workers’ Compensation (WC) claims involving Medicare beneficiaries.

These data collections will have a significant impact on reporting and WCMSA compliance for the use of non-submit and Evidence Based Medicare Set-Aside arrangements. By capturing this new data, Medicare will know when funds have exhausted, make more appropriate determinations regarding the coordination of benefits, and more thoroughly investigate which injury related medical payments they should be denying. The new fields will become effective 4/4/25.

Self-Administration Toolkit, Version 1.6

Under the WCMSA Guidelines, CMS has the right to recovery. Over 1/3 of Medicare recipients have a Medicare Advantage Plan (MAP). These plan providers have asked for the same recovery rights that CMS has. The last sentence in Section 4.1.3 of the new Self-Administration Toolkit takes the first steps to clearly spell out that CMS is extending their rights of recovery to MAP partners:

If you are enrolled in a Medicare Advantage or prescription drug plan, please contact your plan to discuss your WCMSA, if you have not already done so.

WCMSA Reference Guide, Version 4.3

In the latest update of the WCMSA reference guide, Medicare Advantage Plans continue to be spotlighted. In Section 4.1.3, CMS states:

CMS notifies Part C and D plan sponsors that a WCMSA has been approved and instructs plan sponsors to conduct Medicare Secondary Payer (MSP) investigations. However, CMS does not relay WCMSA details to plan sponsors… The administrator must provide details concerning treatments and medications used exclusively to treat a related illness or injury to the plan sponsor so the sponsor may avoid making primary payment in the future.

CMS instructs the MAP sponsors that a WCMSA exists but doesn’t share any specific details of the MSA. It seems inevitable that this will create a communication breakdown at some point. The onus of communication is put entirely on the administrator. For a professional administrator, this will be a common (and new) task, but for someone attempting to self-administer their WCMSA, a whole new world of responsibility and questions are about to be spotlighted.

For the full information on these alerts from CMS, please visit the “What’s New” page of their website.

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467 (Monday – Friday 8am to 5pm EST).

The Medivest Blog

No More Flying Under the Radar