Sanderson Firm's CMPComply Provides Strategic Legal Defense Against Civil Money Penalty Exposure

Civil Money Penalties (CMPs) are no longer a theoretical risk for Responsible Reporting Entities (RREs). CMP audits by the Centers for Medicare & Medicaid Services (CMS) are underway with the potential for imposition of significant penalties for late Section 111 mandatory insurer reporting expected early this year. For RREs, this marks a critical shift from enforcement warnings to real financial exposure of up to $1,000 (annually adjusted for inflation) per day per record for the late report of the assumption of Ongoing Responsibility for Medicals (ORM) on a claim and / or the late report of the settlement, which is otherwise known as the Total Payment Obligation to the Claimant (TPOC).

How does the CMP audit and appeal process work?

CMS will notify the RRE’s Account Representative and the Account Manager if a seemingly non-compliant record is selected during the quarterly audit of 250 randomly selected records. Contact information for the Account Representative and the Account Manager is drawn from the RRE’s annual Profile Report. A noncompliant record will appear to have been reported more than one year after the assumption of ORM and / or the date of the TPOC. 

1. Informal Notice

CMS issues an initial informal notice to the RRE who has 30 calendar days from the date of receipt to respond with a safe harbor defense, mitigating evidence, or other explanation.

2. Notice of Proposed Determination to Impose a Civil Money Penalty

If the RRE misses the deadline or CMS finds the informal dispute response insufficient, CMS issues a Notice of Proposed Determination to Impose a Civil Money Penalty outlining formal appeal rights.

3. Appeal to Administrative Law Judge

An RRE may file a formal appeal to request the matter be heard by an ALJ within 60 calendar days form receipt of the Proposed Determination.

4. Appeal to the Department of Appeals Board

Should the RRE wish to file a formal appeal after receipt of an unfavorable ruling from the ALJ, they must file within 30 calendar days of receipt of the ALJ decision.

5. Petition for Judicial Review

A petition for judicial review must be filed within 60 calendar days of receipt of an unfavorable Department of Appeals Board decision or it becomes binding.

Introducing CMPComply

To help protect against CMPs right now, RREs should take immediate, proactive steps to minimize CMP risk. We strongly recommend having a defined plan in place in the event your organization receives CMP correspondence from CMS as timely, well‑supported responses can make the difference between avoiding a penalty and facing substantial CMP exposure.

As a Medicare Secondary Payer compliance law firm, Sanderson Firm is uniquely positioned to guide RREs through every stage of the CMP audit and appeal process with CMPComply, a comprehensive CMP resolution program designed to protect RREs when enforcement actions arise.

CMPComply includes:

• A seamless referral, response, and review process

• Expert attorney guidance to retrace and defend claims handling decisions

• Identification of applicable safe harbors and relevant mitigating evidence

• Timely navigation and zealous advocacy through the informal dispute and formal appeal process to negate or reduce CMP exposure

The Sanderson Firm Difference

As a well-known and well-respected full-service MSP compliance law firm, we have received high praise for our Section 111 mandatory insurer reporting audit services, and for providing our reporting clients boutique service and support via our robust full-service reporting platform. This cements the fact that Sanderson Firm is deeply committed to working with RREs both before and during CMP enforcement actions to implement a structured resolution strategy that reduces risk and exposure.

To learn more about our new CMPComply service, our Section 111 mandatory insurer reporting services, or how our team of experts can assist you with all aspects of MSP compliance, please Contact Us. We believe that MSP compliance doesn’t have to slow settlements, it simply has to be done right.