Final Rule

Read Time:3 Minute, 54 Second

Regarding Medicare Secondary Payer and Certain Civil Money Penalties

By now you have heard about the October 11, 2023, Final Rule regarding Medicare Secondary Payer, and Certain Civil Money Penalties, in development since January 2013.  CMS received 34 comments in response to the December 2013 Advanced Notice of Proposed Rulemaking (ANPRM), which we were proud to be a part of!   Now, ten years later, the Final Rule has passed effective on December 11, 2023.

What does the Final Rule mean for your Non-Group Health (NGHP) Medicare Secondary Payer (MSP) Compliance program? 

1.     The final rule is Effective on December 11, 2023
2.     The Final Rule is applicable on or after October 11, 2024.  Responsible Reporting Entities (RREs) are expected to be compliant under Section 111 Reporting no later than October 11, 2024, or accept the risk for civil monetary penalties.
3.     Civil Money Penalties (CMPs) are Prospective, occurring after the effective date of the Final Rule, December 11, 2023.
4.     CMS can impose CMPs when the RRE fails to report any Medicare Beneficiary record timely, which is defined as within one year from the date of settlement, judgement award or other payment OR the date when an entity’s Ongoing Responsibility for Medicals (ORM) became effective. 
5.     Accuracy in querying all claims timely to identify Medicare beneficiary status, reporting Total Payment Obligation to Claimant (TPOC) and Ongoing Responsibility for Medicals (ORM), just became more consequential than ever before!  Timeliness and accuracy in reporting are key to avoiding Civil Monetary Penalties.
6.     CMS will identify CMP opportunities via an Audit Process, reviewing a total of 1000 records per calendar year, including both Group Health and Non-Group Health records.
7.     CMS will calculate Civil Monetary Penalties in Three Tiers, based upon the amount of time delayed in reporting a claim involving a Medicare Beneficiary.
o   $250, for each calendar day greater than one year, but less than two years.
o   $500 for each calendar day greater than two years, but less than three years.
o   $1000 for each calendar day greater than three years or more.
o   Penalties will not exceed $365,000.00 (plus an adjustment for inflation) for non-compliance, placing a cap on the total exposure.
o   From the date the non-compliance occurred, there is a five-year Statute of Limitations.
8.     CMPs will not be imposed if a “Good Faith” effort is made to comply, or CMS is responsible for any delays or policy/ procedure changes.
9.     A Notice and Appeal process provides that a Pre-Notice from CMS will be given before issuing a formal CMP and the RRE will have 30 days to respond followed by a CMS review of the evidence. CMS will provide a formal written notice of a CMP.  In addition, a formal Appeal process is available, whereby an RRE can escalate the matter from an ALJ hearing up to a final Judicial Review.
10.  The Final Rule does present some ambiguity involving various terms and technical details, remaining open for future clarification.

Register for CMS’ upcoming Webinar, “Change to Section 111 Worker’s Compensation Reporting Webinar” on November 13, 2023

Feeling a bit nervous about your Risk Protection against Civil Monetary Penalties? 

Fear No More!

Care Bridge International offers the ONLY Enterprise Risk Management Solution for Medicare Secondary Payer (MSP) services, integrating the entire MSP compliance process into a single streamlined platform with Dashboard Analytics, for measuring and monitoring compliance. 


For More Information

To schedule a DEMO of Care Bridge International’s, Enterprise Risk Medicare Secondary Payer Compliance with Dashboard Analytics,  email us at

Meet with Deborah Watkins at the Upcoming MSPN Annual Conference November 8-10, 2023!

Toll Free: 888-434-9326

Follow us at Care Bridge International on LinkedIn

Care Bridge International hosts the largest independent data warehouse in the property and casualty claims industry, consisting of over 16 million workers compensation claims from 43 states. This extensive database allows Care Bridge International to establish adequate medical reserves, valuate medical damages and generate Medicare Set Asides rapidly and accurately, with more risk protection than any other company.

Through our proprietary platform, Bridge-IT, we are bridging the human-technology divide with tools and capabilities placing a greater emphasis on the user interface for increased customer engagement and rich data-driven dashboards that perfectly balance technology driven scale with human-touch to accelerate accurate claim decision-making.