| CMS stands for the Centers for Medicare & Medicaid Services. In relationship to a workers’ compensation claim, CMS is responsible for protecting the Medicare program’s fiscal integrity and ensuring that it pays only for those services that are its responsibility. CMS captures Medicare Set-Aside (MSA) information via the Section 111 reporting process of the Medicare, Medicaid, and SCHIP Extension Act for workers’ compensation settlements. It is currently the position of CMS that while it might be possible to tie a voluntary Workers’ Compensation Medicare Set-Aside (WCMSA) submission to a Total Payment Obligation to Claimant (TPOC) report based on the beneficiary information and Date of Incident (DOI), CMS cannot guarantee that the parties are using the voluntary WCMSA amounts, as parties may have decided to use an Evidence-Based MSA, another type of unsubmitted MSA, or otherwise settled future medical where a case does not meet review thresholds. Therefore, effective April 4, 2025, CMS started mandating Section 111 reporting of WCMSA data for all settlements (including those with zero dollar allocations) involving injured workers who are, or were Medicare beneficiaries. This includes any settlements below the CMS review threshold of $25,000.00. In general, the Responsible Reporting Entities (RRE) who must report per Section 111 are self-insured employers, liability insurers, workers’ compensation insurers and third-party administrators. This reporting is mandatory, regardless of whether the WCMSA is approved by CMS or not. Per CMS: Failure of an RRE to comply with its reporting obligations may result in CMS utilizing all available statutory and regulatory options to recover mistakenly made payments, including bringing an action against the RRE under the False Claims Act. Section 111 reporting is not a replacement for submission of settlement documents which is still required by CMS to finalize the WCMSA approval process. CMS review remains voluntary and the review thresholds are unchanged. Despite the fact that not all cases involving future medical settlements are eligible for CMS review, CMS review and approval is the only process that offers both Medicare beneficiaries and defendants finality. When CMS approves a proposed WCMSA amount, CMS will stand behind that amount. Without CMS’s approval, Medicare may deny related medical claims, or pursue recovery for related medical claims that Medicare paid up to the full amount of the settlement, judgment, award, or other payment. Not all cases are “eligible” for an opportunity to be approved by CMS, yet all settlements consider Medicare’s interests. Therefore, it is more important than ever to have an accurate understanding of future medical exposure in all cases involving future medical settlements. Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement? Contact us for more information! Schedule time to discuss how MSS can assist you identify and value your client’s future medical care needs! Click here for more information. Stay tuned for Part II of our MSA Reporting Series – Reporting a Medicare Beneficiary’s Workers’ Compensation Claim to CMS Note: The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice. |
| Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement, review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you! |