On Thursday, April 25, 2013 Panelists John P Albert – Acting Director, Division of Medicare Secondary Payer Policy and Operations; Cynthia Gross – Health Insurance Specialist, Division of Medicare Secondary Payer Policy and Operations; Elizabeth V. Poole – Health Insurance Specialist, Division of Medicare Secondary Payer Policy and Operations; and Barbara Jean Wright – Senior Technical Advisor, MSP were welcomed by almost 200 members of the National Alliance of Medicare Set Aside Professionals at its annual conference in Baltimore, Maryland. During the one hour presentation, CMS Panelists discussed various changes to the CMS website, the Statement of Work (SOW) for the new WCRC Contractor for completing and returning determinations in a timely manner for newly submitted WCMSAs, the new web-portal for submissions/re-considerations and the recent CMS Town Hall Teleconference. They also responded to attendee’s questions.
Changes to CMS Website
CMS reiterated that over the past several years they have been working diligently to make the CMS website more “user-friendly” more efficient and easier for the user to find information. The Coordination of Benefits and Medicare Secondary Payer tabs of the CMS.gov website are undergoing updates. The first completed phase is the WC Agency Services Section which has been replaced by the WCMSA section. One of the most significant improvements is a tab for “new information.” All newly released information will be housed and maintained for one year, after which it will be archived but remain accessible. The URL for direct access is: http://www.cms.gov/Medicare/Coordination-of-Benefits/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Overview.html
Established Turnaround Time for WCRC
CMS made it clear that when the new contract was awarded to Provider Resources, Inc. (PRI) it implemented a Statement of Work (SOW) to ensure timely responses to allocations submitted in the established WCMSA process. For new allocations, the WCRC now has twenty two (22) business days to review a proposal that is “clean.” In other words, if the WCRC does not need to “develop” or request for additional information, Allocators should receive the CMS determination within twenty two (22) working days after receipt by WCRC. If the WCRC is required to develop for additional information, there will be an additional 17 days from the date of receipt of the information. If the correct information is not received, then an additional 17 days will be added. It is therefore important to submit all information at the time of initial submission and, where additional development requests are made, to provide the requested information in a timely manner in order to shorten the response time.
The new web-portal is up and running and CMS expressed extreme satisfaction with the fact that the utilization of the web-portal as compared to paper submissions is greater than what was originally anticipated. More than 90% of all allocations are submitted through the web-portal which is designed to be the most efficient means for the WCMSA process. Electronic submissions are encouraged over paper submissions.
CMS Townhall Teleconference April 9, 2013
The CMS Panelists reiterated that one of the focuses of the WCRC contract with new Contractor PRI is outreach and education. To that end, CMS held its first of what it hopes to be many such Town Halls in the coming years. They expect to have similar Town Hall conferences twice per year. The recent teleconference Town Hall was viewed as a great success with Pharmacists, Clinical, and Legal representation from PRI answering very detailed questions and providing key operational information. CMS expects to publish a transcript of the April 9, 2013 call as soon as it obtains approval to do so. It is anticipated that there will be about 37 pages of single-spaced typewritten information in the transcript. Due to the ongoing confirmation process for the CMS Administrator, the dissemination of the transcript to the public is on hold until the confirmation process is completed and authorization is provided to release the information. The transcript is expected to be a good resource for individuals who were not able to attend the teleconference. Ms. Gross did, however, point out that while every attempt was made to clarify and provide accurate information during the call, the written memoranda and policies of the agency always prevail over information provided in an oral forum such as the teleconference. CMS is also looking to social media to facilitate its reach through the use of Twitter, Facebook and U-Channel.
Denied Claims for Medicare Beneficiaries with Open Workers Compensation Claims
The CMS panel addressed the issue of denied claims for Medicare beneficiaries and stated that the fact that there is an open MSP occurrence or common working file should not result in denial of benefits for Medicare beneficiaries. The panel believed that the situation is improving and that there is, unfortunately, nothing that vendors can do with this issue. They reiterated that physicians are required to bill correctly and that the agency has been completing additional edits and are looking at eliminating certain codes to minimize the incidence of denied claims. However, CMS maintained that most cases were appropriately denied mostly due to the fact that the affected beneficiaries did, in fact, have other insurance that was primary to Medicare.
A few FAQ’s
CMS had a few pre-approved questions that were submitted in advance of the visit. The responses were no surprise to the industry and were as follows:
Q: Since pricing an MSA is not an exact science, why doesn’t CMS accept the allocation as submitted?
A: The CMS response (which garnered a huge laugh from attendees) essentially indicated that Allocators have their own assessment of future Medicare related expenses and CMS has its own.
Q: Will CMS ever provide a new determination when the claim does not settle and things have changed?
A: No. CMS reiterated that they do not have enough resources to re review submissions and that WCMSA’s should not be requested prior to the point of MMI so that the claimant’s condition is stable and future care can be reasonably evaluated.
As CMS usually anticipates settlement within four months of an approved WCMSA, if the parties are not reasonably expected to the settle, the WCMSA should not be submitted until there is reasonable certainty that a settlement will occur. Once an approval is offered, absent a mistake or because CMS has misconstrued the evidence, the parties will be unable to obtain a revised allocation.
Q: What sources does CMS use for Usual and Customary Charges and why are State Laws not followed in pricing decisions?
A: There is no direct system that is used for pricing. The panel reiterated that the WCRC utilizes evidence based treatment guidelines and multiple sources are used. It is not the Agency’s intent to include services that are not covered by the WC state law. However, it is up to the parties to address anything that is not covered by the state law and provide the specific information directly in the MSA. The specific arguments must be outlined. Ms. Gross further stated that if the state law does not cover unauthorized case, it is not the CMS intent to price care related to unauthorized treatment. All arguments as to authorization must be made specifically within the MSA.
All in all, the visit from CMS was viewed as an overwhelming success by both the CMS panelists and NAMSAP conference attendees.
Gary Patereau, of the Louisiana Association of Self Insured Employers, certainly deserves the thanks of the Alliance and all attendees as does the NAMSAP Board of Directors for orchestrating the very informative CMS visit. Gould & Lamb will continue to keep you advised of any important developments regarding WCRC processes, procedures and news as it is received