A year into CMS’s new Section 111 WCMSA reporting requirements, the compliance equation has shifted on every Medicare beneficiary settlement
For years, workers’ compensation carriers operated against a familiar line: settle a Medicare beneficiary’s claim below CMS review thresholds, and the often onerous Workers’ Compensation Medicare Set Aside (WCMSA) review process stayed out of the picture. That approach resulted in the Centers for Medicare & Medicaid Services (CMS) having limited visibility into future medical allocations in settlements below the $25,000 review threshold, leaving a blind spot for a significant number of claims.
That gap closed on April 4, 2025, when CMS began requiring additional information at the point of Section 111 settlement reporting through five new WCMSA fields. The agency indicated it wasn’t getting the settlement information needed to close out the claims it was reviewing, and the historical practice of following up with documentation after the fact had broken down across the industry. The fix was to require that data be provided at the point of settlement reporting.
A year in, the downstream effect is clear. CMS now sees workers’ compensation settlements that used to sit comfortably below its MSA review threshold, and because the agency rolled out civil monetary penalties (CMPs) in the same timeframe, the risk of inaccurate reporting has moved from theoretical to material.
Your team says this is handled. Your Section 111 reports say otherwise.
A consistent pattern is showing up across casualty insurers since go-live: adjusters are defaulting to $0 in the new WCMSA fields, especially on settlements under the historical $25,000 threshold. Some carriers believe their teams have this covered. The reporting data often says otherwise.
The reasons are practical:
A wrong zero on a Medicare beneficiary settlement has two consequences. First, CMS notices the pattern. The full penalty ramifications are still catching up to the policy, but the exposure is real and growing. Second, the beneficiary is potentially hurt: They settle, no future allocation is recorded, and when they go in for an x-ray related to the work comp injury, Medicare may deny payment. They pay out of pocket.
What the right technology solution does
A purpose-built WCMSA compliance automation solution should address three specific considerations across the claim lifecycle: 1) identifying when an MSA is needed; 2) producing a defensible allocation for small settlements, and 3) validating what gets reported to CMS. Each maps to a distinct point in the claim, and each requires functionality that general claims platforms weren’t designed to provide.
What makes a solution genuinely end-to-end isn’t any single feature. It’s that Section 111 data, MSA data, and lien information coincide in one integrated environment. When an adjuster or compliance lead needs to address “I got an MSA,” “I want CMS submission,” “I have a lien I forgot about,” or “My Section 111 reporting says this, what’s going on?”—those answers should come from one place, not four. That cross-system visibility is what separates a connected solution from a collection of point tools, enabling your data to work harder for your teams across departments.
A Medicare-aware alert layer your system doesn’t have
Claims systems do a lot of things well. Medicare compliance is not always one of them. The right automation solution offers the missing layers.
What that looks like in practice: When a claim involving a Medicare beneficiary reaches the point where settlement may be likely, the system prompts the adjuster directly. It recognizes potential Medicare compliance needs and lays out the available paths against the relevant thresholds, whether that means a standard WCMSA or a data-driven allocation for below-thresholds settlements, or deferring the decision if the claim isn’t currently positioned for settlement. To help keep claims on track, the system can automatically initiate an MSA if no action is taken within a reasonable window.
Two things make an alert layer useful in day-to-day claims handling. First, it focuses attention on the smaller population of Medicare beneficiary claims within an adjuster’s caseload but carry great compliance risk. Second, it surfaces at a moment when action is needed, rather than buried in a queue. Just as important, the solution should be configured to fit your workflow and protocols, so timing, default actions, and trigger criteria align with how your teams actually operate.
A defensible allocation for the sub-$25K claims that used to get $0
For settlements with a Medicare beneficiary under $25,000, a traditional MSA rarely makes economic sense. These claims typically have limited future medical needs, and the cost of a traditional MSA is prohibitive. Historically, that is why the future medical component of these claims was bypassed. As of April 4, 2025, ignoring this isn’t a luxury.
A data-driven allocation methodology fills that gap. The approach uses Section 111 data already on file to produce an allocation that reflects the specific injury profile and the claimant’s life expectancy, drawn from CDC tables. The models behind it draw on one of the largest workers’ compensation data sets in the industry, driving a credible number quickly and at a cost that fits the claim. The output is unique to the individual’s claim.
Three things to look for in this kind of functionality:
A validation layer between your adjuster and CMS
Section 111 reporting is where the WCMSA amount becomes part of CMS’s record, making accuracy before submission critical. As CMS continues to operationalize the new requirements, a pre-submission validation step can help carriers reduce avoidable errors and improve reporting consistency.
That validation should catch two common issues.
This gives adjusters a clearer review point before submission and helps carriers strengthen reporting accuracy as the new process continues to take shape.
How it comes together on a single claim
A composite walk-through:
Picture a Medicare beneficiary settling a work comp claim under the new rules. The alert layer surfaces the claim when settlement starts to look realistic and points the adjuster toward the right path—standard MSA, data-driven MSA, or a deferred decision. If a data-driven MSA allocation is the right fit, it comes back within 48 hours, and settlement moves forward. When the adjuster goes to report through Section 111, the validation layer checks the numbers against what’s already on file and against the settlement document itself, catching any mismatches before it becomes CMS’s official record.
Trigger at the front end. Allocation in the middle. Validation at the back end. Each closes a gap the others can’t. Together, they keep the claim from defaulting to the wrong number at any point along the way.
If you do one thing
Of the three, the most direct line to civil monetary penalty exposure runs through Section 111 reporting. If you can only put one piece in place first, start with the validation layer. What arrives at CMS via Section 111 is what CMS treats as final, and a pre-submission check is the difference between catching an error and explaining one.
All three matter. But validation is where the penalty teeth live, and it’s the most concrete step you can take this quarter to make sure the right number is the one CMS keeps on file.
What “good” looks like in 2026
Two years ago, “good” Section 111 compliance meant accurate reporting on settlements with a Medicare beneficiary. In 2026, “good” means substantial, holistic compliance addressing future medical needs for all workers’ compensation claims settling with a Medicare beneficiary with the right allocation prompted at the right point in the claim lifecycle, and validation at the moment of submission, so the wrong number never becomes CMS’s authoritative record.
The right automation solution makes that the default, not the exception.
Get started
Ready to see how an integrated Medicare compliance automation solution can optimize your protocols? Learn more at verisk.com/medicare-compliance.
