CMS References Civil Money Penalties in Updated NGHP User Guide
Written by: Gerardo Sanchez
On January 22, 2024, the Centers for Medicare & Medicaid Services (“CMS”) released a new version 7.4 of the Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Worker’s Compensation User Guide (“NGHP User Guide”), located here. The updated version of the NGHP User Guide adds a new section outlining Civil Money Penalties (“CMPs”) to Chapter III, Section 5.1. While the information added is not new and has been published as part of the Final Rule released late last year, it does mark the official inclusion of CMP language into the NGHP User Guide which CMS had advised would be forthcoming during this month’s Town Hall Teleconference.
Of note, the updated language in Section 5.1 of the NGHP User Guide serves as a reminder that instances of non-reporting will be captured within CMS’ audit process. Previously, some Responsible Reporting Entities (RREs) were under the impression that they would not be subject to CMPs if they simply never reported Medicare beneficiary claims given that CMS’ originally proposed audit methodology did not appear to be able to capture simple non-reporting. The new NGHP language confirms, in writing, that CMS’ auditing process will capture both Section 111 records and records submitted to CMS outside the Section 111 reporting process. An example of this would be a case where a Responsible Reporting Entity (“RRE”) fails to report a settlement, judgment, award, or other payment made to a Medicare beneficiary (“Total Payment Obligation to the Claimant”, or “TPOC”), but CMS is ultimately made aware of the event by the Medicare beneficiary’s attorney notifying CMS of the settlement. According to CMS, Section 111 submissions and records from sources outside of Section 111 submissions will be audited “to ensure that CMS does not miss situations where an RRE has entirely failed to report the occurrence.”
We are pleased to see CMS reference CMPs in its written policy materials. Before this NGHP User Guide update, there were no written references to CMPs in the policy guidance. Please keep in mind that the NGHP User Guide language does not provide an exhaustive breakdown on CMPs, and interested individuals should still consult the Final Rule for more information regarding CMPs.
Sanderson Firm is available for assistance through our reporting solution SandersonComply which provides primary payer clients with a purpose-built, user-friendly tool for accurate and timely Section 111 reporting compliance. SandersonComply also includes data pre-validation, EDI and API data integration, automated file submissions (and more), which streamlines an otherwise challenging and cumbersome Section 111 reporting process.
If you have any questions regarding CMS’ NGHP User Guide update, would like to schedule a demo for SandersonComply, or have any other Section 111 reporting-related inquiries, please contact us.
