CMP Avoidance: Part 1 – Quarterly Files and Threshold Errors
For anyone who has lost track of the date during these challenging times, today is Friday, July 31st. We are now three full months past the submission cutoff for comments on the proposed rule for Civil Money Penalties for Section 111 reporting. We do not know when CMS will make the next move, or what the next move might be. It took six years for CMS to go from the advanced notice of proposed rulemaking comment period closure on February 10, 2014 to starting the comment period on the proposed rule on February 18, 2020. CMS may move swiftly, although history suggests that may not be likely. We also have to consider that a final rule may not be the next step, and that given the number of submissions and lack of detail in the proposed rule, that there may be another round of comments solicited with CMS revising the proposed rule.
However long the wait is until the next move by CMS, now is the time to act. One of the areas identified in the proposed rule where CMS believes money penalties could be assessed involves a scenario where four out of eight quarterly file submission trigger the twenty percent error threshold. Here is an excerpt from the proposed rule for this area of penalization:
“If a GHP or NGHP entity has reported, and exceeds any error tolerance(s) threshold established by the Secretary in any 4 out of 8 consecutive reporting periods. We propose that the initial and maximum error tolerance threshold would be 20 percent (representing errors that prevent 20 percent or more of the beneficiary records from being processed), with any reduction in that tolerance to be published for notice and comment in advance of implementation. We intend for this tolerance to be applied as an absolute percentage of the records submitted in a given reporting cycle; we welcome feedback on this proposed methodology and threshold. The errors that would be used to determine whether the error tolerance is met must also be defined in advance of implementation of the final rule; we are only considering those significant errors which prevent a file or individual beneficiary record from processing. These errors are defined in the Section 111 User Guides, but we welcome the public’s feedback. We would maintain the current notification process in place where RREs receive notice via response file and direct outreach (email and, in more serious cases, telephone call) when there are errors with their file submissions.”
Let us backup for a moment and look at the past 10 years of history in reporting claims. CMS has file handling rules in place that will halt a file from being processed if they detect that twenty percent or more of the claim records are incomplete or in error of validation rules. Those errors are detected in a staging process so once that threshold is hit processing is stopped and the BCRC contacts the RRE to let them know of the issue. E-mails are also generated that go to the Account Manager registered for that RRE ID.
Now here’s the good news on this area of money penalties…an RRE should never get penalized for this issue! If I could, I would dramatically walk out onto a mountain ledge like Charlton Heston holding stone tablets in The Ten Commandments and proclaim “Thou shalt not report invalid or incomplete data to CMS!” Reporting is not new, and the validation rules have been stable for a long time. The only changes CMS has made recently are adjustments to ICD diagnosis codes. There is no reason an RRE should get even one quarter in excess of twenty percent errors let alone four in eight consecutive quarters.
An RRE has several pathways available to get their claim data to CMS including the use of third-party administrators (TPAs) or reporting/recovery agents. Some do choose to report directly if they have the resources to do so. But no matter how the data gets to CMS, make sure your reporting process has strong validation rules applied to your claim data. Take steps now to ensure bad and incomplete data is not being sent in your quarterly files.
I have seen a lot of different strategies in this industry over the last decade. If your reporting agent or TPA is putting all your claim data into your quarterly file, regardless of it passing validations, it is time to have a serious conversation with them. If you are doing this in your own process, it is time to rethink your strategy. There are reporting partners out there that will help you correct that issue and be sure to ask them what their accuracy rating is in responses returned from CMS, as it is critical with this movement towards CMPs.
Also remember that the NGHP User Guide is clear on this topic in chapter IV – Technical Information – under section 7.1 where it states:
“Note: RREs should not submit a record known to be missing required data elements. Submitting a record known to be in error will not make the RRE more compliant or serve any other purpose. Prior to submitting claim information, the RRE should obtain all required information, correct all known errors, and then submit the claim record.”
This is one area where you can easily prevent CMS from assessing Civil Money Penalties, whereas the other two areas defined in the proposed rule are more complex. Alleviating yourself of the burden of risk around threshold error file submissions will allow you to focus on the other areas CMS will be evaluating.
Not sure where to start? Well in my next article, I will try to provide some guidance to help an RRE frame the above advice with an actionable checklist. Visibility is critical, and I will tell you what to look for throughout the file submission process.
Resources:
Federal Register: CMS-6061-P (This link will take you to the proposed rule text)