Section 111 Audit Uncovers Reporting Gaps

At the request of a Liability and No-Fault insurance carrier, Sanderson Firm performed a targeted audit of its Section 111 Mandatory Insurer Reporting (S111) data, which was handled at the time by its third-party administrator (TPA). The carrier initiated the audit after receiving inquiries from claimants and formal correspondence from various  Medicare contractors, raising concerns about the accuracy and timeliness of their Section 111 reporting.

Key findings from the audit included:

• TPOC Reporting Gaps: No Total Payment Obligation to Claimant (TPOC) data had been reported for several years' worth of Liability claims. While adjuster diaries had been created, the corresponding data had never been transmitted to Medicare.

• Lack of No-Fault Reporting: No-Fault data, including reports to assume and terminate Ongoing Responsibility for Medical (ORM) had not been reported for Personal Injury Protection (PIP) coverage associated with the Liability claims, representing a significant compliance oversight.

Following these findings, the carrier transitioned its Section 111 reporting responsibilities to Sanderson Firm. In cases like this, Sanderson Firm assists the carrier and its TPA in a remediation process, which includes submission of relevant outstanding data to bring the carrier into full compliance and ensure timely and accurate reporting of both ORM and TPOC events—thereby mitigating risk and potential exposure to Civil Money Penalties (CMPs).