CMS Issues Alert Regarding Proper Reporting of Policy Limits in No-Fault Claims

Today, October 26, 2021, the Centers for Medicare & Medicaid Services (CMS) Issued an Alert which states the following:

Alert: Reporting of Incorrect No-Fault Policy Limits

Responsible Reporting Entities (RREs) are accountable for ensuring the information included in their Section 111 MMSEA Mandatory Insurer Reporting submissions is accurate. There may be situations where, depending upon state law or the terms of a given policy, the policy limit may vary. In these situations, the reported Policy Limit should reflect the actual amount the RRE has accepted responsibility for at the time the record is submitted or updated. Just as important, if the Section 111 record needs to be corrected to reflect a different Policy Limit, the RRE should update the record as quickly as possible to reflect the new policy limit. For example, if a policy allows for a minimum amount of MedPay coverage and will only allow a higher amount under certain circumstances, and those circumstances are not yet met at the time of reporting, the RRE should report the lower amount. Should the criteria that triggers the higher policy limit be met after that report, the RRE should update the record as soon as possible. Reporting of an incorrect Policy Limit or failing to timely update the record can put the RRE at risk of non-compliance with the Section 111 reporting requirements.

Inaccurate and/or uncorrected information can impact current Medicare claims payment actions. Inaccurate and/or uncorrected information also places the RRE at risk of recovery actions and increases the burden of proof upon the RRE should it attempt to dispute recovery efforts. Therefore, we advise the RRE to consider contacting their EDI Representative to submit an off-cycle Section 111 report with new policy limit information, rather than wait for their next Section 111 reporting cycle.

Sanderson Firm Commentary: No-fault payers (such as MedPay and auto carriers/payers) should take note of this important Alert from CMS. As noted within the Alert, the reportable policy limit amount directly impacts the amount that CMS can recover in conditional payments. Thus, if a policy amount is inaccurate or reported as greater than the amount currently triggered under the no-fault policy, this inaccurate reporting may enable CMS to recover a larger amount in conditional payments, and as noted, the burden would then be on the RRE to prove that the amount reported was inaccurate. As CMS and its contractors are constantly analyzing Section 111 data to drive conditional payment recoveries, CMS suggests that no-fault payers submit and correct inaccurate policy limit information in an off-cycle Section 111 report so as to update CMS’ records more quickly. For questions on this Alert or MMSEA Section 111 compliance, please contact us.