CMS Issues New Alert Regarding Incorrect Reporting of No-Fault Policy Limits

A single red light bulb hangs in a dark room. Beside it, the word "Alert" glows brightly.

By B. Smith

On October 26, 2021, CMS issued an alert addressing the importance of accurately reporting no-fault policy limits as part of Section 111 Reporting. CMS acknowledged that policy limits may vary based upon state law or contract terms. In these situations, CMS notes that the reported policy limit “should reflect the actual amount the RRE has accepted responsibility for at the time the record is submitted or updated.” To illustrate this further, CMS provides the following example:

[I]f 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.

CMS warns that reporting inaccurate or “uncorrected” information can impact current Medicare claim payment actions, put the Responsible Reporting Entity (RRE) at risk of recovery actions, and increase the burden of proof on the RRE in the event they dispute recovery efforts. CMS further advises RREs to consider contacting their assigned EDI representatives to submit off-cycle reports with the new policy information, rather than waiting until the next reporting period.

Although this alert applies only to no-fault policy limits, failing to accurately report Section 111 data to CMS can result in additional costs, potential penalties and Medicare Secondary Payer compliance issues. As CMS continues to prepare for Civil Monetary Penalties, now is the time to determine if your Section 111 data is actually being reported to CMS and if what you are reporting is accurate. To learn more about our Section 111 Systems Review, please contact NuQuest Settlement Consultants at [email protected].