Compliance and Workers' Compensation ORM Thresholds

If the first presentation of claim does not meet the threshold it does not have to be reported.  If a subsequent claim exceeds the threshold, then claim has to be reported using the CMS Date of Incident associated with the initial claim.  If the subsequent claim is reported one quarter (minus the 45 day grace period) or later, then the report will result in a compliance flag.  Although Medicare may not seek to impose the $1,000.00 per day penalty, the RRE should maintain detailed records of the payments and payment dates to defend any assertion of a penalty for late reporting.


CMS had stated in the past that an RRE could report any payment, judgment or award, now they will reject a payment (or combined payments) that do not meet the threshold; however, timeliness penalties will be assessed according to when the threshold was broken, not based on the first payment or the date of incident.  The RRE no longer has to report all payments to avoid a possible late reporting violation if a claim subsequently exceeded the threshold and triggered a report.