MMSEA Section 111 Reporting Requirements: The 365-Day Rule and What It Means

Under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA), understanding and adhering to the reporting requirements is crucial for Responsible Reporting Entities (RREs). A key component of these requirements is the 365-Day Rule, which governs the timeliness of record submissions to the Centers for Medicare & Medicaid Services (CMS).

Overview of the 365-Day Rule

The 365-Day Rule stipulates that RREs must report records within 365 days of specific triggering events. These events include:

• Total Payment Obligation to Claimant (TPOC) events, which involve any settlement, judgment, or payment.

• Ongoing Responsibility for Medicals (ORM), which pertains to instances where an entity assumes ongoing payment responsibilities for a beneficiary’s medical care.

Successful reporting requires that all records are not only submitted but also accepted by CMS within that 365-day timeframe. If submissions are made after this period, they may be subject to penalties under the new Civil Money Penalty regime.

Key Considerations

CMS defines what constitutes a timely report based on different dates associated with the claims:

• For TPOC Records: The date of settlement, judgment, award, or payment.

• For ORM Records: The effective date when the RRE assumes responsibility for ongoing medical payments, which could be the date of an incident or the date the beneficiary becomes eligible for Medicare, among others.

Implications of Noncompliance

Failing to submit records within the specified timeline can lead to severe financial ramifications. The potential penalties are substantial and can escalate based on the duration of the delay:

• Records reported 1 to 2 years late: $250 per day per record.

• Records reported 2 to 3 years late: $500 per day per record.

• Records reported over 3 years late: $1,000 per day per record.

Compounding this issue, penalties can be influenced by inflation adjustments, making timely compliance even more critical.

Practical Takeaways

• Establish Timelines: RREs should create a robust system for tracking and managing reporting deadlines to ensure compliance with the 365-Day Rule.

• Documentation is Key: Maintain meticulous records of all communications related to TPOC and ORM events, as these will be vital in case of audits or disputes.

• Seek Expert Guidance: Regularly consult with MSP compliance experts to keep your knowledge up to date on evolving regulations and best practices.

By prioritizing these reporting requirements and understanding the implications of the 365-Day Rule, RREs can significantly mitigate the risk of noncompliance and associated penalties, paving the way for smoother operations within Medicare’s framework.

Do you have questions about your responsibilities for compliance? Please let us know if you would like to discuss your Medicare Secondary Payer compliance with an experienced team.