MMSEA Section 111 Audits

On October 2, 2012, Daniel R. Levinson, inspector general of the DHHS, released a work plan that indicated that GHPs will be audited for compliance with reporting requirements under MMSEA Section 111. Specifically, the work plan states that “[w]e will determine whether selected non-Medicare health plans properly reported insurance coverage information to Medicare as required.” For a copy of the work plan, please click here (see top of page 36).

Although the work plan does not detail plans for audits of NGHPs, it would seem that NGHPs would be next in line since the requirements of reporting for NGHPs followed shortly after the GHP requirements. An article posted on WorkCompCentral (subscription required) notes commentary by Don White, Levinson’s spokesman: “We were referring to a review of conventional health care plans, and there is nothing included in the plan to audit casualty companies. But certainly, because there is an overlap and we might be working on audits in the casualty industry in the future. At this point, there are no reviews scheduled of workers’ compensation or other property and casualty carriers included in the work plan.”

The work plan does not discuss levying of fines for noncompliance; however the U.S. House Ways and Means Committee is reviewing proposed legislation which would impose guidelines around how and when the $1,000 per day per claim fine can be imposed. The SMART Act, which seeks reform surrounding conditional payment reimbursement and fines imposed under MMSEA Section 111, passed the House Energy and Commerce Subcommittee on Health on September 11, 2012 and will now head to the full Committee on Energy and Commerce for a vote before floor consideration in the House.

As the DHHS has now indicated they will begin audits in 2013 and legislative guidelines are currently being formulated surrounding fines for noncompliance with MMSEA Section 111, CMS is surely sending signals that enforcement efforts are underway. Both GHPs and NGHPs would be wise to ensure they have made good faith efforts to comply with any reporting requirements under MMSEA Section 111.

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