It's hard to imagine, but every single claim reported to Medicare under Section 111 reporting requirements has the potential to generate 199 error codes! The full list is available online from CMS in the reporting user guide.
And, of course, that number only applies assuming the correct claims are reported in the first place, submitted in the correct format, at the correct time.
The minutia involved in submitting Section 111 reporting requirements creates a complicated - and potentially costly - problem for many Responsible Reporting Entities (RREs). After all, Medicare can penalize RREs up to $1,000 per claim per day for claims that are not properly reported.
Here are some common issues RREs run into when reporting claim payments made to Medicare beneficiaries:
1. Choosing the wrong claims
Section 111 requirements apply only to Medicare beneficiaries. However, it's important to note that many Medicare beneficiaries are under the age of 65. Unfortunately, some RREs run into heavy fines for non-compliance simply because they overlook Medicare beneficiaries who are younger.
In addition, there are thresholds beyond which Medicare does not require claims to be reported. Specifically, liability claims under $1,000 are not required to be reported.
2. Filing at the wrong time
Every RRE is assigned a specific 7-day window once each quarter during which they are to file all of their Section 111 claims reports. If claims are reported outside that window, it can lead to processing errors or long delays in processing the reports.
3. Reporting in the wrong format
CMS will only accept Section 111 reports in a specific electronic format. No hard copies, faxed copies, e-mails, or verbal reports will be accepted. To meet this requirement, RREs must know and follow the proper format, and also have the technology in place to consistently report all necessary claims using that format each quarter.
4. 199 error codes
If the issues above have been avoided and the right claims are being reported at the right time using the proper format, there are only 199 more things that can go wrong.
In nearly all of these cases, data entry errors are to blame. If the information is not entered perfectly according to the field-by-field requirements CMS has put in place, the report can be rendered invalid and potentially be subject to the $1,000 per day fine for non-compliance.
The easiest solution to all these problems:
Without a doubt, this is a lot to absorb. It's also a lot to try to remember if you're a claims examiner that only sees a few Medicare-related claims a month.
Most RREs don't have the personnel and infrastructure in place to guarantee that every single appropriate claim is being caught and reported accurately according to every rule outlined by CMS. To implement all the necessary changes would require a tremendous investment in time and money.
The easiest way for any company to ensure 100% compliance with Section 111 reporting requirements and avoid all penalties related to non-compliance is to outsource your reporting and recovery process to professionals who handle these claims day in and day out. At Flagship Services Group, this is our specialty. We are the only Medicare compliance services company that provides a “100% Medicare Compliance Guarantee,” when all suggested policies and procedures are followed.
Contact us to discuss how we mitigate risk and protect your financial resources.