ExamWorks Clinical Solutions Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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ExamWorks Clinical Solutions ("ECS") is pleased to offer its comments on the Proposed Rule regarding Medicare Secondary Payer and Certain Civil Monetary Penalties. 85 Fed. Reg. 8793 (
ECS is a national provider of Medicare Secondary Payer compliance solutions for the property / casualty insurance community. Our organization was formed in 2014 through the acquisitions of Gould & Lamb and MedAllocators. ECS, along with Gould & Lamb and MedAllocators, has provided MSP compliance services since 2000. Our clients are among the largest employers, insurers, and third party administrators ("TPAs") in
Our comment represents our assessment as well as that of many of our clients who have participated in the review and analysis of the Proposed Rule. They represent the informed experiences of claims leaders and claims professionals, attorneys, and information technology experts who have been in the trenches as Section 111 reporting has transformed the way the industry addresses Medicare Secondary Payer compliance. As the Agency no doubt appreciates, the effort to comply with Section 111 of the MMSEA has required not only a tremendous technological investment, but also a significant recalibration of claims handling. The industry has near universally adopted the Agency's terminology and processes, even as the Agency has - in many cases - failed to grasp the very real unintended consequences of its often vague or contradictory guidance./1
It is therefore disappointing that the Agency proposes to issue rules that would in many ways reward behavior that runs counter to CMS policy and the MSP principles of coordination of benefits and recovery. Perhaps even more troubling, the problematic choices illuminated by the Proposed Rule are precisely the issues that the industry has been asking the Agency to resolve for the better part of the last decade. Our comments focus significant attention on these contradictions, but they will also highlight several positive aspects of the Proposed Rule. Ultimately, we ask that CMS constructively evaluate these comments and consider substantial modifications to the Proposed Rule, including eliminating the aspects that may incentivize CMS' conditional payment contractors to perform a form of vigilante justice.
A. Situations subject to penalty
CMS proposes three categories of malfeasance which may be subject to a civil monetary penalty. For the purposes of this comment, we will broadly group these situations as: 1) Failure to Report; 2) Contradictory Information Identified; and 3) Poor Quality Reporting. We will provide detailed commentary on each category, including recommended alterations, as follows:
1. Failure to report
As proposed, CMS would be entitled to levy civil monetary penalties whenever an RRE "fails to report any beneficiary record within 1 year from the date of the settlement, judgment, award, or other payment." Within the supporting statement, CMS indicates that this section would apply if lump sum settlements are reported more than one year after the "TPOC" date./2
We are pleased with two aspects of this portion of this proposal.
First, we are pleased that CMS chose a bright line beyond which RREs could be susceptible to penalties. This bright line creates a clear deadline for RREs to acquire information necessary to report and - importantly - it allows parties time to communicate and confirm important information that could prevent inappropriate recovery claims (e.g. ICD codes, date of incident, and date of settlement). We believe that one year is, in general, sufficient to procure information and report claims data. Coupled with the safe harbors discussed below, we recommend that CMS retain the one year timeframe.
Second, we are pleased that CMS rejected the temptation to assess CMPs whenever a "Compliance Flag" was triggered under the current Section 111 reporting framework. Compliance flags are established via the Section 111 NGHP User Guide and are presently transmitted in the settlement context whenever a "TPOC" is reported more than 135 days "older than the File Received Date." One year is more than enough time for an RRE to determine that it has a reporting obligation, collect responsive information, and report the claim via Section 111 reporting. To align with the Proposed Rule, we strongly urge CMS to adjust existing '01' Compliance Flag to only issue for TPOCs reported more than one year beyond the reported settlement date./3
Falling within this category is the outright failure to register. CMS acknowledges "At this point in time, the reporting program has not yet reached a level of maturity where we have definitively identified any additional RREs that have failed to register and report as required." (Emphasis added.) It is surprising that - ten years into the program - CMS would acknowledge such a failure. Anecdotally, insurance industry professionals can easily identify RREs who may believe (erroneously) or may be unaware (surprisingly) of their obligation to register to report; develop systems or processes to identify Medicare beneficiaries; and report certain required information on a quarterly basis. As a matter of fundamental fairness, it is frustrating that CMS would deploy absolutely no process to identify RREs that are actively defying Federal Law even as it would seek to penalize entities who have made good faith efforts to report. CMS should develop sources of information and methodologies to better identify these recalcitrant RREs and, where appropriate, focus any penalties first among these entities which have ignored the reporting obligations.
2. Contradictory information Identified/4
In contrast with the "late TPOC" portion of the proposed rule, we believe CMS' proposal to penalize ORM contradictions unearthed in the recovery process is not only poorly conceived and unnecessarily vague, but also incredibly counter-productive. If enacted, the proposal to penalize "contradictions" will lead to improper, premature ORM termination and may actually subvert CMS' goal of obtaining accurate information to coordinate benefits and recover. As noted below, we strongly urge CMS to scuttle this aspect of the proposal.
i. Vague language, applicability, and criteria
CMS' proposal is unworkable for a number of very practical reasons, primarily associated with the incredibly vague language in the proposed rule itself; the complete lack of clarity surrounding what behavior, exactly, would prove to be contradictory; and the long history of CMS intransigence regarding the critical opportunity to craft useful and sensible ORM termination criteria for long-dormant claims.
CMS proposes to issue civil monetary penalties where "An applicable plan's response to CMS recovery efforts contradicts the entity's reporting under section 1862(b)(8) of the Act." For the last four and a half years CMS has employed multiple contractors as it has deployed a rolling "ORM recovery" process designed to recapture Medicare payments made while an RRE has declared its responsibility to pay for related medical benefits. For a time, the ORM recovery process was a fiasco. Although CMS and its newly designated Commercial Recovery Center (CRC) have rebounded from failures of the prior contractor, we cannot assume the process will always go smoothly. Nor can we assume that a successor contractor will fairly assess reported "contradictions" uncovered in the recovery process./5
CMS has established no substantive standards for what types of information does or does not "contradict" previously reported information. Moreover, while the Agency suggests that it would only penalize situations where an RRE "directly contradicts its own reporting," the draft rule places no such conditions upon the type of contradiction, implying that an indirect or di minimus contradiction could still be subject to penalty. "Contradictions" may manifest themselves in the recovery process in multiple ways, but we examine three categories: 1) ORM termination contradictions; 2) ICD-9 or 10 contradictions; and 3) other miscellaneous contradictions. We strongly urge CMS to reject the entire concept, as follows:
1. ORM Termination Contradictions. In the only example cited by CMS, the agency focuses on an RRE that "repeatedly affirmed ongoing primary payment responsibility for a given beneficiary, then responded to recovery efforts with the assertion that coverage for that beneficiary actually terminated 2 years prior to the issuance of the recovery demand letter." ORM termination "contradictions" can be unearthed in the recovery process for a variety of practical, policy-oriented, and di minimus reasons. Policy-oriented reasons are identified below, but practically speaking it is not unusual for ORM to remain "open" pursuant to CMS' Section 111 reporting guidelines even as the claim is - for all intents and purposes - resolved. The Proposed Rule does not differentiate between such di minimus contradictions and situations where the RRE has not seriously attempted to comply with the statute. Moreover, there are a number of practical circumstances wherein a recovery dispute or appeal may appear to "contradict" previously reported information and where the Agency or its recovery contractor may mistakenly interpret the dispute or appeal as "contradicting" prior reporting./6
Absent clear regulatory guidance, penalizing RREs in this manner is unfair and (as indicated below) totally out of proportion for the harm to the Agency or its beneficiaries.
2. ICD-9 or 10 code contradictions. We believe it would be a significant miscarriage of justice for CMS to assess penalties for ICD codes that may be "contradicted" during the recovery process. Nevertheless, some commentators have suggested that the Agency may use this vaguely drafted "contradiction" language to do just that./7
There are many practical and technical reasons why the use of ICD codes as "contradiction" predicate should be off limits. ICD-9 codes are still accepted for some Section 111 reporting claims (claims with dates of injury prior to
Absent specific guidance, CMS should clearly and unequivocally reject the inference that an RRE could be penalized over a mere misunderstanding concerning previously reported ICD codes. To do so would be unnecessarily punitive and wholly disproportionate to the harm to the Agency or its beneficiaries.
3. Other miscellaneous contradictions. CMS should likewise disregard other contradictions which may, on the surface, appear important but which do not materially or substantially impact CMS' core MSP mission of coordinating benefits and appropriately recovering. Misunderstandings regarding the date injury or incident, insurance type, and other miscellaneous items may provide some ephemeral appeal to the Agency or its contractor if uncovered during the recovery process. Yet these seemingly critical misunderstandings are not instances of "noncompliance" with the statute. Such "contradictions" in do not substantively undercut CMS' core coordination of benefits and recovery activities and CMS should reject their deployment.
ii. "Back door" around prospective enforcement.
Some commentators have suggested that "contradictions" unearthed in the recovery process could act as a "back door" to retroactive enforcement of civil monetary penalties. Examples cited by these commentators have suggested that CMS could go back several years prior to the development of a final rule and assess penalties for contradictions uncovered during recovery activities occurring several years later, after the publication of the final rule.
CMS must clearly and unequivocally reject such suggestions. Whatever the motivation for these suggestions, imposing civil money penalties on claims reported years prior to the development of a final rule would be grossly improper and punitive to the regulated community. RREs have been required to report claims data to Medicare for almost a full decade. For much of that decade RREs have relied upon often vague, occasionally contradictory, and oft-shifting policies as pronounced from a five volume User Guide that now runs to several hundred pages. Penalizing RREs for data reported as far back as 2011 - as these commentators suggest - would act as improper back-door around CMS' promised "prospective" enforcement and impose a ridiculous expectation that CMS could entirely subvert the Agency's declaration that it "would evaluate compliance based only upon files submitted by the RRE on or after the effective date of any final rule." (Emphasis added.)
iii. ORM termination modification has been rejected by CMS for the last several years.
For at least the last five years the industry has repeatedly urged CMS to relax its policies with regard to not only ORM termination, but also the obligation to continuously monitor claims that are closed but "subject to reopening."/9
CMS has been presented with reams of data that clearly demonstrate that the "tail" on these claims is significant, and that a large volume of queries represent claims that are administratively closed for which CMS has no conceivable recovery claim./10
As a result of CMS unwillingness to resolve this issue, RREs are presently querying for Medicare entitlement on countless administratively closed claims which are theoretically "subject to reopening," but which do not fall neatly within the narrow ORM termination criteria established by Medicare.
Simply stated, because RREs are functionally prevented from terminating ORM on dormant, closed claims, their appeals often lead the recovery contractor to assume (falsely) that ORM should have been terminated./11
With this background, CMS now seeks to double down on the issue and possibly impose penalties whenever a recovery claim occurs on one of these long-dormant claims. As indicated earlier, recovery contractors cannot be trusted to adequately understand the intricacies of Section 111 reporting and there is tremendous risk that RREs will be improperly "turned in" by a contractor simply because the RRE exercised its appellate rights. Simply stated, it is completely incomprehensible that CMS would impose penalties for "contradictions" unearthed by recovery contractors who issued an improper demand because CMS refused to modify its policies and allow an RRE to terminate ORM on a long-dormant, closed, and inconsequential claim.
iv. Penalizing "contradictions" will actually undermine CMS' coordination of benefits and recovery objectives.
The proposal to label reporting "contradictions" as "noncompliance" will force RREs to be far more aggressive in terminating ORM, likely to the significant detriment of CMS' MSP program. Simply stated, RREs will be motivated to avoid leaving ORM open, thereby tempting fate. The motto will become "when in doubt, terminate."
The penalty for noncompliance is potentially catastrophic. Rather than leave it to chance that CMS' contractor will identify a "contradiction," it is likely that some RREs will be tempted to aggressively move to terminate ORM whenever it can colorably suggest that responsibility to pay for medical is no longer "presently assumed." While "contradictions" are easy to identify in the recovery process, it will be almost impossible for CMS to identify premature ORM termination short of an audit of the RRE's claims system(s)./12
CMS should perform an RRE-centric cost benefit analysis, which will almost certainly demonstrate that the cost of maintaining open ORM is far greater than simply terminating more aggressively. For CMS, the stakes are far greater than they are for RREs who choose to prematurely terminate. If RREs act more aggressively, and in some cases prematurely, to terminate ORM CMS will be unable to coordinate benefits or recover and will - ultimately - bear costs as the primary payer./13
vi. The Proposal to treat "contradictions" as "noncompliance" places RREs in an impossible "Hobson's Choice."
CMS proposes to completely undercut RRE's rights under the statute by providing them an impossible choice: either pay Medicare's improper recovery demand or, by the mere act of appealing the demand subject itself to potentially existential penalties for reporting contradictions. An impossible Hobson's Choice to be sure, and quiet possibly a violation of the Fifth Amendment to the United States Constitution. At the very least, the stark dilemma presented to RREs clearly establishes that CMS' proposal is arbitrary, capricious and violative of Federal Law. For this reason alone, CMS must withdraw the proposal.
3. Poor quality reporting
Finally, CMS proposes to penalize any RRE that "has reported and exceeds any error tolerance(s) threshold established by the Secretary in any 4 out of 8 consecutive reporting periods."/14
Clearly, CMS must have a mechanism to impose penalties upon RREs who regularly provide nonviable reporting. While we are, in general, comfortable with this concept we ask CMS to strongly consider clear and unambiguous guidelines that do not either lead to penalties for otherwise properly-reported claims, or result in stacking of penalties on the same claim or claims.
i. File suspension
Under the current Section 111 reporting framework, the Benefits Coordination and Recovery Contractor (BCRC) will suspend processing any file wherein "20% or more of the total records failed, with a disposition code of 'SP', due to errors." (See Section 111 NGHP User Guide, v. 3.0, Ch. 4, p. 7-9). Because the BCRC will suspend processing the file or - in some cases - not even be properly process the file, entire files will be delayed or disregarded by the BCRC. CMS should take care to not throw the baby out with the bath water. We strongly urge CMS to exempt from "late reporting" or "contradictory reporting" penalties any otherwise properly reported claims that are "suspended" from processing due to the volume of erroneous claims in the file.
ii. Stacked penalties
We urge CMS to resist the temptation to "stack" penalties on claims impacted by the threshold errors. RREs should not find themselves essentially paying the same penalty twice for the same behavior. Put another way, any penalty assessment should run concurrently and should not be cumulative on a per calendar day basis.
"Stacking" penalties can conceivably occur in a multitude of situations. For example, an RRE could report in excess of 20% errors, subjecting the RRE to quality-oriented penalties. Because the RRE's claim file suffers delayed processing due, it would be possible that some otherwise error-free claims to be reported more than one year beyond a TPOC date. In another example, an RRE could report a TPOC and ORM termination date late. The late TPOC could be subject to late reporting monetary penalties and the ORM termination date could create a "contradiction" with the recovery process. Those claims should not then be subject to multiple types of penalties on the same claim, for essentially the same Section 111 reporting.
To avoid this outcome, CMS should adopt a "no stacking" rule. Simply stated, under a "no stacking" rule CMS would not be permitted to either: 1) Penalize any RRE for more than one instance of non-compliance, per claim; or 2) Penalize any RRE for late and/or contradictory reporting when that late and/or contradictory reporting was caused directly or indirectly by processing delays with CMS' contractor, including processing delays associated with threshold errors.
B. Amount of the penalty
CMS should withdraw all NGHP proposals at proposed s. 402.105 in favor of model that fairly assesses penalties in light of the harm to the Agency; the RRE's specific intent or culpability as signified by the word "noncompliance;" the RRE's pattern of behavior; the scope of the allegedly "noncompliant" reporting; and other equitable considerations. As proposed, RREs would be subject to draconian (in many cases, existential) penalties for di minimus, non-consequential mistakes made in the reporting process. Such a scheme would place an undue risk on small RREs, many of which are small businesses that may only report a few claims per year. The scheme challenges smaller RREs, but even large RREs will be impacted by outrageous penalties of greater than a half-million dollars per claim per year for minor reporting errors as a result of excusable neglect./15
C. Situations not subject to penalty
We are generally pleased that CMS chose to specifically identify situations not subject to any penalty, including safe harbors where an RRE is unable to confirm Medicare status in conjunction with a settlement, judgment, award, or other payment. The proposed rule, which can be described as the "two and one" rule, would not impose penalties whenever an RRE has two written and one electronic communication seeking to identify Medicare coverage. We propose that CMS create a temporal limitation on the "two and one" rule. A large percentage of liability claims resolve within 60 to 90 days. We propose that CMS develop an alternative for these so-called "Fast Track" claims that does not require the RRE to mail two letters and attempt one electronic communication.
We also recommend that CMS clarify the applicability of safe harbors in the asbestos bankruptcy trust situations and other mass tort incidents. In many of these situations, RRE(s) are unable to get information sufficient to report claims, even post-settlement. At present, RREs are instructed in CMS' User Guide that an RRE's reporting obligation is triggered only when the RRE is able to connect an injured party to a specific TPOC amount. When all information is not identified at the time of the settlement, RREs are permitted to delay reporting and provide "he date these criteria were met" in the "Funding Delayed Beyond TPOC Date" field. CMS should clarify it will not initiate penalties in these situations from the TPOC date, but rather will look to delayed use of the "Funding Delayed Beyond TPOC Date" field./16
D. Statute of limitations and prospective enforcement
It is disappointing that CMS has elected to utilize a five year statute of limitations rather than the three year limitations period designated for "actions by
E. Appeals
CMS proposes that the existing Administrative Law Judge (ALJ) act as the primary appellate body for any civil monetary penalties appeals. While CMS' support of the ALJ program is noble, by any measure the ALJ program is essentially broken. The average ALJ case takes 1,372 days to complete./17
It is no light criticism to refer to a Federal judicial body as "essentially broken," but the ALJ program is hopelessly backlogged. In the last three fiscal years the backlog has grown by nearly 500 days. At this rate, an appeal filed today would not be resolved until early 2025 - meaning it will have sat unresolved for an entire presidential term.
CMS should forge an alternative appeals path. The stakes for RREs are simply too great. As we have demonstrated, left unaltered the civil monetary penalty regime proposed by CMS is arbitrary, capricious, unfair, and needlessly punitive. CMS need not force RREs to either pay exorbitant penalties in order to avoid accrued interest or - perhaps worse - see an overly punitive penalty exponentially grow. CMS can develop a streamlined, independent, appeals program for these claims so that a penalty assessed in 2021 has a chance to be resolved within an appropriate time period.
Conclusion
On behalf of our clients and employees, ECS appreciates the opportunity to provide commentary on CMS' proposed rule on Medicare Secondary Payer civil monetary penalties. Thank you for your consideration and please do not hesitate to contact us directly with any questions or concerns.
Sincerely,
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Footnotes:
1/ Section 111 reporting requirements are near-completely refereed by CMS' NGHP User Guide. This guidance represents agency policy and is not subject to rulemaking. The User Guide is often contradictory and lacks specific guidance in a number of critical insurance situations, leaving RREs to simply guess at what is the correct action in a given situation.
2/ More specifically, CMS indicated that it will assess penalties "If an RRE fails to report any NGHP beneficiary record within the required timeframe (no more than 1 year of the date of the settlement, judgment, award, or other payment (also referred to as the Total Payment Obligation to Claimant (TPOC))." Based on the language in the proposed rule as well as the supporting statement, we believe that CMS proposes to penalize late reported settlements and not late reports of ongoing responsibility for medicals (ORM). We urge CMS to retain this aspect of the proposed rule and not penalize late ORM reports.
3/ CMS should consider simplifying the TPOC date to the date payment is made in all situations, regardless of the date of the settlement agreement or judicial approval.
4/ We submit CMS that has no authority to even penalize "contradictions" uncovered within the recovery process. Section 111 of the MMSEA, as amended, authorized the Agency to impose civil monetary penalties "of up to
5/ CMS acknowledges that it lacks tools to substantively address "contradictions" and that it "will enhance monitoring of recovery process disputes and appeals that contradict reported data." Although not addressed by CMS in the Proposed Rule, we ask that CMS affirmatively reject any suggestion that the CRC or any other recovery contractor could obtain a "finder's fee" or any other incentive for the discovery of purported "contradictions." The standard is too vague and the temptation is too great. Such temptations, we believe, led to the prior contractor's near complete ignorance of guardrails that were placed upon the recovery demand process.
6/ By way of example, CMS may issue demands months or years after a claim has essentially resolved but outside of the strict ORM termination guidelines provided within the CMS NGHP User Guide. The RRE may appeal the demand and provide evidence that the claim is "resolved." This does not "contradict" prior reporting, yet the penalties regime outlined by the Agency would force the RRE to subject itself to potentially multiple years of appeal in order to avoid potentially hundreds of thousands of dollars of improper penalties due to a simple (avoidable) misunderstanding.
7/ While we make no judgment on these commentators, the Agency should take notice of the potential motivations of individuals or entities who support or lend credence to ICD-9/10 "contradictions" or "back door retroactive application" discussed herein.
8/ CMS' NGHP User Guide advises that "The ICD-9/ICD10 codes provided in these fields must provide enough information for Medicare to identify medical claims related to the underlying Injury, Incident or Illness claim reported by the RRE." (See NGHP User Guide, v. 3.0, Ch. 3, p. 6-10). "Must provide enough information" lacks specificity as a standard and helps explain why different RREs report claims that are likely very similar but (to CMS) may appear to be quite different.
9/ The Section 111 NGHP User Guide captures the obligation to continuously (endlessly) query administratively closed ORM claims as follows: "An RRE could set up a process to collect and save injured party information on a tracking file, as ORM is assumed and as TPOCs are established. The injured party information for claims that require ongoing monitoring would be included as well." See NGHP User Guide v. 5.8, Ch. 4, p. 8-2.
10/ CMS representatives have directed RREs to monitor these claims for several years, with no end in sight. For example, "As we've said all along, if you have responsibility for ORM and someone is not eligible at the time that's established, you have to monitor and if they are still eligible for ORM when they become a beneficiary, report that." (
11/ To be clear, if an RRE is truly responsible for medical treatment it must pay for the treatment or pay the conditional payment demand. Examples abound, however, of individuals who suffered minor or inconsequential injuries over a decade ago whose claims are currently being queried due to CMS' open ended "monitoring" requirements for any claim that was open on and after
12/ Given that CMS has yet to establish any way to identify RREs that have never even registered to report, we doubt that CMS will have the resources to establish any meaningful auditing program.
13/ We do not mean to suggest that RREs would act improperly. Rather, we suggest that RREs will necessarily be far more aggressive at managing claims in such a way that allows them to terminate ORM as soon as possible. Given the often-vague standards deployed within the User Guide, it is likely that aggressive claims handling will lead to inadvertent premature ORM termination.
14/ The Secretary has presently established a 20% "error tolerance threshold" within the Section 111 NGHP User Guide. We appreciate CMS' acknowledgement that the Secretary would not arbitrarily reduce this threshold ("any reduction in that tolerance to be published for notice and comment in advance of implementation") as well as CMS' relatively narrow definition of "errors" as "those significant errors which prevent a file or individual beneficiary record from processing." (See Proposed Rule at 8798). Because errors that prevent a file or individual beneficiary record from processing are not only well-defined within the Section 111 NGHP User Guide but also longstanding, we provide no additional comment beyond urging CMS to maintain this framework with no modification. If modification is sought, we strongly urge CMS to utilize the notice and comment rulemaking process.
15/ Rather than reward RREs making a "good faith effort" to report, CMS proposes to actually penalize the RRE that makes a good faith effort to report information, albeit with some mistakes. CMS' position is perplexing, as the Agency's basic admonition for the last decade has been for RREs to report accurate information, but to not worry if contradictory information is sorted out in the recovery process. The about face by CMS is - at the very least - troubling.
16/ CMS also should clarify that it will not penalize RREs relying upon side agreements to exempt RREs from Section 111 reporting that are provided by the Agency in the context of a mass tort Lien Resolution Administrator.
17/ Thirteen hundred seventy two days is an impressive three years and nine months. For perspective, 1372 days from
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2013-0266-0037
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