Section 111


What is Section 111 of the Medicare/Medicaid SCHIP Extension Act?

Also referred to as Mandatory Insurer Reporting, MIR, Medicare Reporting and SCHIP Reporting, Section 111 of the Medicare/Medicaid SCHIP Extension Act (MMSEA) was signed into law in December 2007 and requires Non-Group Health Plan (Workers’ Compensation, Liability and No-Fault) Responsible Reporting Entities to report qualifying claims to Medicare in a specific format and timeframe.  The Act serves 4 purposes for Medicare:

  •          Discover billions in unresolved Medicare liens (conditional payments) and seek immediate recovery
  •          Cease making ongoing conditional payments in the future
  •          Ensure that all settlements “adequately consider” (allocate) Medicare’s interests as required by law
  •          Potential of up to $1,000 per day, per claim fine for non-compliance
    •          Initially estimated at $1.1B in fines to fund State Children’s’ Health Insurance Programs

In its simplest definition, Section 111 Mandatory Insurer Reporting enforces the Medicare Secondary Payer Act, and non-compliance may result in severe monetary penalty.


The ExamWorks Clinical Solutions Difference

ExamWorks Clinical Solutions has the largest and most experienced team of MMSEA Compliance Managers serving the industry.  From mundane Annual RRE Recertifications to complex analysis of claims for reporting to Medicare, the MMSEA Compliance Managers assist every step of the way.

The proprietary MMSEA platform is the industry’s largest and most sophisticated platform available.  From manual data entry via the web portal to fully integrated data file exchanges, the ExamWorks Clinical Solutions platform ensures that all types of client systems can integrate successfully and easily.  Features include:

  •          Simple, intuitive web portal to provide claims data
  •          Secure file exchanges via SFTP / HTTPS
  •          Data scrubbing features that result in unmatched CMS acceptance rates
  •          Dedicated technical and compliance support


Business Intelligence

ExamWorks Clinical Solutions’ business intelligence portal allows ExamWorks Clinical Solutions to create reports that measure clients' compliance rates and assist in client stewardship activities.

TPAs, manage claims for countless Responsible Reporting Entities (RREs).  Analysis of a TPA’s MMSEA performance will make certain the TPA is providing the best possible service to its clients.  The ExamWorks Clinical Solutions business intelligence suite of reports provides TPAs with RRE-level insights to determine metrics related to data cleanliness and potential gaps in business processes.

Carriers and self-insured entities (also known as RREs) are ultimately responsible for MMSEA compliance, not the TPAs.  Therefore, it is imperative to know how well the TPAs are performing to ensure the RRE is complying with Medicare’s requirements.  The ExamWorks Clinical Solutions business intelligence suite of reports provides the carrier or self-insured entity with full visibility into each TPA’s performance, analyzing cleanliness of data, timeliness of correcting errors and acceptance rates at Medicare.

ExamWorks Clinical Solutions continues to search for opportunities to utilize data to enhance clients’ compliance programs and outcomes.