If you make payments to Medicare beneficiaries, you are required to report them under Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA). MMSEA supports transparency between payers and Medicare to improve benefits administration, but reporting can be tricky business. You need to set up the right software, identify the right people and follow the right timelines.
To help you avoid violations and simplify MMSEA reporting, we put together this MMSEA Section 111 user guide.
What Is MMSEA Section 111?
MMSEA Section 111 created mandatory reporting requirements for organizations that make certain payments to Medicare beneficiaries with group health plans (GHP) or non-group health plans (NGHP), including liability insurance, no-fault insurance and workers’ compensation. A party subject to Section 111 requirements is called a responsible reporting entity (RRE). These include GHP and NGHP organizations that function as an insurer or self-insurer. RREs may also include plan administrators or fiduciaries for self-insured or self-administered plans. In some situations, third-party administrators (TPAs) or other agents are delegated by RREs to manage the Section 111 reporting process, but the ultimate responsibility for Section 111 reporting remains with the RRE itself.
A quick background of Medicare can help us explain MMSEA Section 111 further. Medicare was introduced back in 1965 as a primary source of payment and amended in 1980 to be a secondary source. With this update, called the Medicare Secondary Payer Statute (MSP), workers’ compensation and primary insurers became the primary payers. The statute limited Medicare’s responsibility for these benefits, but it requires significant data transparency to enforce. The MMSEA reporting requirements aim to support enforcement through amendments to MSP.
One notable, recent update to MMSEA comes from the Provide Accurate Information Directly (PAID) Act, which Congress passed in late 2020. It helped NGHP RREs better identify Medicare beneficiaries with improved data from the Centers for Medicare and Medicaid Services (CMS). It offers more details about enrollment, including participation in Medicare Advantage (Part C) or a Prescription Drug (Part D) plan, to ease reporting demands for RREs.
CMS introduced MMSEA Section 111 to help identify primary payers and support more accurate benefits payments. In other words, it helps CMS avoid paying for benefits that should be covered by primary insurance providers. It also authorizes CMS and RREs to exchange health insurance information electronically. While Section 111 reporting supports a necessary part of Medicare administration, it also adds some challenges for RREs, who must dedicate time and energy to accurate, timely reporting.
Penalties of Non-Compliance With Section 111 of MMSEA
Non-compliance with CMS MMSEA Section 111 can come with steep fines, including civil money penalties (CMPs) of up to $1,000 per claim per day. The statutory maximum penalty is up to $365,000 per beneficiary per year. CMS proposed limiting these penalties in February 2020 with a 3-year standardization time limit, but the final ruling timeline has been extended to Feb. 18, 2024. After the ruling is published, CMS can levy penalties, so RREs must ensure a dependable reporting process ahead of this deadline.
Who Has to Report Under MMSEA Section 111?
RREs can be insurers or self-insurers. For self-insured or self-administered plans, the RRE is the entity which funds payment on the plan’s claims. While RREs can use agents or TPAs to help with reporting, the RRE remains responsible for the accuracy and on-time submission of the reports.
Each quarter, RREs must submit electronic data on liability, no-fault and workers’ compensation claims for Medicare beneficiaries. CMS will then confirm the injured party’s Medicare status and confirm acceptance of the claims.
How Do I File a Section 111 MMSEA Report?
Filing an MMSEA report is technically challenging, and with such hefty fines, you will want to get it right. The reporting process for MMSEA Section 111 includes the following steps:
- Before you can submit anything, you will need to obtain an RRE identification number from CMS and establish a method of communicating with CMS’s platform, called an electronic data interchange (EDI). EDI provides a secure data exchange and standardized formatting, but it requires a specific type of platform that can be difficult for organizations to set up independently.
- You will also need to determine which people are Medicare beneficiaries according to CMS’s criteria. Age is insufficient on its own, so finding beneficiaries might be challenging. You need to submit key information about each claimant, such as social security numbers, names and dates of birth, to Medicare’s query tool to look for a match and get a corresponding Medicare ID to use with your claims.
- After identifying the Medicare beneficiaries within your claims, you must submit detailed reports quarterly, during a CMS-assigned submission window, and process responses from CMS to identify errors. Errors could render your claim unreported and affect compliance. Integrating your current claims system with the EDI process can be very helpful to give you visibility into the process, catch errors, and avoid data re-entry.
Throughout the process, you must stay up-to-date on any changing CMS requirements and protocols, such as the PAID Act, and maintain a thorough audit trail. This audit trail should reveal any interaction that someone has had with the claim and will be needed if CMS decides to investigate your organization.
What About the Direct Data Entry (DDE) Option?
Alternatively, you can use the Direct Data Entry (DDE) claim submission method offered by CMS. However, this option is open to RREs that plan to submit less than 500 claims per year and it should also be noted that each add, update and delete transaction counts toward this annual limit. DDE submitters are bound to all of the NGHP User Guide requirements. The DDE option is not intended for RREs with significant claim volume since only one claim report can be submitted at a time but is a useful, no-cost option if an RRE has only a handful of claims to report each year.
MMSEA Section 111 Reporting Software
Since many components are involved in MMSEA reporting, NGHP RREs often use a dedicated program to handle Section 111 reporting requirements. A software platform can greatly improve your ability to submit reports accurately and on time. It streamlines the process and helps you avoid the human error of manual processes. Some tasks that an MMSEA reporting platform can offer include:
- Identifying Medicare beneficiaries
- Validating submissions for errors prior to submission, avoiding rejections
- Keeping an audit trail
- Providing detailed reporting
- Integrating with claims software to avoid manual data re-entry
- Handling all the complexities of EDI
Despite the complex nature of mandatory insurer reporting (MIR), a software system should be user-friendly. Employees can spend less time navigating Section 111 requirements or creating opportunities for errors. Cloud-based MMSEA Section 111 reporting programs are particularly valuable, allowing you to access data from any device and location. They also let the provider update the system as needed, such as when CMS changes its requirements.
Streamline Your Section 111 Reporting With MIR Express™️
Government reporting does not leave room for error, so look for a platform you can depend on. MIR Express™️ is built for NGHP Medicare reporting and packed with features for reliable, efficient compliance. We have an acceptance rate of over 99.96% over millions of submitted claims, and we offer guaranteed on-time reporting during an RRE’s assigned reporting periods. With automated monthly and quarterly submissions, MIR Express™️ helps you streamline MMSEA Section 111 reporting and breathe easy.
The platform comes at a flat rate and is completely unbundled: you will not need to pay for additional managed services or contracts. MIR Express™️ is fully integrated with Cloud Claims, to deliver a complete end-to-end claims and Section 111 compliance solution! Let MIR Express take the stress and complexity out of Section 111 reporting requirements. Learn more about MIR Express or reach out to us today!