CMS Confirms Bad Data Reporting Will Not Provide Compliance

PMSI’s MedicareConnectsm platform has been designed to submit claims data according to CMS requirements and guidelines.  PMSI’s methodology has always included omitting claims records containing incomplete or erroneous data from being submitted to CMS. Submitting files containing errors and missing data serves no purpose because the data cannot be adequately processed and used for proper coordination of benefits. 

Conflicting techniques and opinions from the industry led PMSI to confirm our approach with CMS directly and on the September 21, 2011 MMSEA Section 111 teleconference, CMS confirmed that reporting incorrect or incomplete claims records (which prevent full processing to completion due to errors) does not constitute compliance with Section 111 regulatory guidelines. Submitting incomplete or erroneous files is equivalent to not submitting the data at all and will not make the RRE any more compliant than if the claim was never submitted. There is no benefit to submitting an incomplete record or a record that will not be accepted due to errors.  RREs should obtain all required information and then submit the claim record. 

CMS previously issued an Alert dated February 24, 2010 which states that the following is one of the requirements for an RRE to remain compliant with Section 111 reporting: 

“Throughout the reporting process the RRE consistently follows CMS data submission protocols, producing quality file submissions and data that can be adequately processed and used.”

Additionally, CMS confirmed the following in regard to reporting incomplete or erroneous claims:

  • CMS and the COBC do not store information about records submitted and rejected (containing errors) at the claim record submission level. Only summary statistics on error counts per Claim Input File are preserved. It is as though the individual claim record was never submitted.
  • CMS and the COBC monitor error submission levels.  Follow-up has already begun and will continue with RREs submitting a higher volume of records in error on a repeated basis.
  • CMS is not currently pursuing the imposition of fines and the immediate goal is to work with RREs to improve the quality and timeliness of their claim record submissions.

In light of the above information from CMS, PMSI believes the best approach for RREs to take in regard to Section 111 reporting is:

  • Proactively collect required data elements for reportable claims
  • Submit clean claims- do not submit a claim record which is missing a required data element as CMS has confirmed they are tracking error levels for RREs
  • Submit required claim reports in a timely fashion

RREs are ultimately responsible for the accuracy and timely reporting of their claims data. RREs that have retained the services of a reporting agent and/or TPA should identify the following:

  • What does the data collection process entail and how are efforts to collect missing required data fields documented?
  • When and how will the RRE be notified of claims which are missing required data elements and will not be accepted by CMS (may miss the quarterly reporting deadline)? 
  • Will your reporting agent and/or TPA diligently communicate and work with the COBC to minimize your risk of noncompliance?
  • Do you as the RRE have the appropriate visibility into the reporting mechanism you have chosen? (Are employees of your organization acting as the account manager and/or account designee so that you can regularly monitor the file transmission history via the COBSW? Do your reporting agent and/or TPA provide you with compliance reports?)

PMSI understands the importance of the issues and concerns surrounding the Section 111 process.    Regular notifications are provided to our clients not only reminding them of upcoming deadlines for quarterly claims reporting, but also a full review of the status of each claim. PMSI also gives the RRE or their data providers a real-time view of claim status and errors, allowing them to focus on the claims needing additional or corrected data before being sent to CMS.  RREs can rely on MedicareConnect to determine whether a claim meets CMS reporting thresholds with up-to-date validation and business rules. This ensures that only required claims are reported to CMS and removes risks associated with over-reporting claims that have not met the thresholds. MedicareConnect transmits your clean, validated claims to CMS per the required schedule assuring that your file will not be rejected because of threshold errors and that each claim is error free for acceptance by CMS.


Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.