medicare-set-aside Archives

Celebrex and Abilify Price Drops Trigger MSA Reductions

December 14, 2020

Vial of pills illustrating MSA Reductions in RX costs

Recently, the lowest average wholesale price of Celebrex 200mg and the price of multiple strengths of Abilify dropped dramatically resulting in major MSA reductions.

A widely used, non-steroidal anti-inflammatory drug, Celebrex (Celecoxib), is FDA-approved for several conditions:

Ankylosing spondylitis
Juvenile rheumatoid arthritis
Acute migraines
Osteoarthritis
Acute pain
Primary dysmenorrhea
Rheumatoid arthritis

Per Red Book, the lowest average wholesale price for Celecoxib 200mg dropped from $1.79 to $0.33, an 81.56% price reduction.

Abilify (Aripiprazole) is an antipsychotic drug FDA-approved for the following conditions:

Schizophrenia
Acute treatment of manic and mixed episodes associated with bipolar
Adjunctive treatment of major depressive disorder
Irritability associated with autistic disorder
Treatment of Tourette’s disorder

Per Red Book, the lowest average wholesale price for multiple strengths (2mg to 30mg) of Aripiprazole dropped from the $30 to $36 range to a range of $0.07 to $0.17 per dose, an almost 100% price reduction.

Tower Action in Response

Because Tower’s system tracks all medications allocated in MSA reports, we have already pulled reports from the past two years that allocated these medications and advised clients of the potential for MSA reductions. You can also contact us to determine whether a particular MSA qualifies for MSA reductions. Revisions to the MSA can be done now or prior to MSA submission to CMS.

Please contact Dan Anders, Tower’s Chief Compliance Officer, at Daniel.anders@towermsa.com or (888) 331-4941 with questions.

Need a Medicare Set Aside Second Opinion?

October 27, 2020

nurse conducting research for a Medicare Set Aside Second Opinion in a manual

Has a Medicare Set Aside ever disrupted one of your settlements? Any one of these things — unexpected medical, surgical or pharmacy costs, compliance issues, the way MSA administration will be handled, or the presence or absence of a structured settlement–can halt negotiations.

Tower addresses cost drivers and deals with compliance situations long before preparing an MSA, so our clients don’t have to worry about MSAs impeding settlements and injured workers can be assured that their future medical needs will be met .

However, recently we’ve been asked to review MSAs prepared by other companies and found significant cost drivers and other obstacles to settlements. Fortunately, our free Medicare Set Aside Second Opinion service saved the settlements and helped to secure claim closures.

Medicare Set Aside Second Opinion Case Study

Here’s one case. Based on her experience with managing a claim and its costs, an adjuster thought the $220,000 MSA produced by another MSP provider was too high and asked us to review it.

Following our standard workflow for new MSAs, our Intake Team compared the MSA’s “accepted body parts” against the client’s claim system and found significant discrepancies.

The MSA allocated for a lifetime’s supply of sertraline, a drug used to treat anxiety and depression. However, “psyche/stress” was not an accepted body part and the workers’ comp insurer had not been paying for it.

Tower drafted a Body Part Letter that clarified the compensable conditions and specified those that were not accepted by or paid for by the insurer. Removing the drug from the allocation saved more than $58,000.

This 2^nd Opinion review also detected recommendations for inappropriate medical treatment, including an unnecessary bladder surgery. Our Physician Follow Up Service – available at no extra cost to our clients – contacted the physician and obtained written confirmation of this, reducing the allocation by another $37,000+. We also obtained a rated age from K.P. Underwriting that further reduced the treatment and prescription cost over life expectancy. The total savings came to over $98,000.

MSA Value is in Claim Closure

How could we do this when the other provider couldn’t? It comes down to our philosophy and attitude.

Tower does not treat MSAs as commodities. Instead, we recognize that the real business value of an MSA is in its ability to facilitate claim settlement and closure.

Our role is to collaborate with clients to analyze and assess risk, review medical and pharmacy records to determine Medicare exposure, intervene when treatment changes are needed, and recommend the appropriate time to complete the MSA.

In short, we proactively work to reduce costs and posture files for settlement.

How We Achieve Settlement Success

We created MSA best-practices technology and continually update it to make sure we can always accurately allocate the MSA without overfunding. Our MSP Automation Suite contains the very latest CMS coverage, coding and individual state pricing data. We measure everything and analyze CMS responses line by line so we know what the agency will accept, what it won’t and when to push.

We know where cost drivers tend to hide, and our Intake and Clinical Teams are trained to hunt them down. We know which interventions to apply at the right time to reduce costs. We know how to phrase treatment and pharmacy changes and supply the precise documentation CMS needs to approve the MSA.

And we do all this the first time around, so you won’t need a second opinion.

With Tower, payers can enter settlement negotiations with realistic MSAs that they can explain and defend. (We’ll participate in these negotiations if you’d like.)

Settle well the first time with Tower. But, if you have a questionable MSA, let us give you our free 2^nd opinion. Download more information here or refer an MSA for a 2^nd Opinion by contacting our Intake Team at 888-331-4941 or referrals@towermsa.com.

CMS Adds New Pricing Resource to WCMSA Reference Guide

October 14, 2020

stethescope on a Workers’ Compensation Medicare Set-Aside Arrangements

In a recent update to its WCMSA Reference Guide, the Centers for Medicare and Medicaid Services released a state-by-state list of the major medical centers it uses for pricing future medical expenses in proposed MSAs. This zip code-based list (See Appendix 7 of the guide) will help MSA preparers and submitters more accurately price surgical procedures, including spinal cord stimulators and intrathecal pumps, per CMS requirements.

Background

From the reference guide:

Hospital fee schedules are currently determined using the Diagnosis-Related Groups (DRG) payment for the median major medical center within the appropriate fee jurisdiction for the pricing ZIP code, unless otherwise defined by state law (see Appendix 7).

While that sounds good, until this update, no one but CMS and the Workers’ Compensation Review Center (WCRC), which reviews submitted MSAs for CMS, knew for certain the major medical center.

Nonetheless, Tower’s experienced clinical team has historically been successful in identifying appropriate facility pricing, thus avoiding significant variances between the proposed surgical pricing and the CMS calculation. The release of the list removes any remaining uncertainty.

Practical Implications

The list of major medical centers should eliminate one area of variances in surgical pricing. (Variances can still occur based upon differences in the type of surgery allocated or the components of the allocated surgery.) In short, it should lead to more accurate pricing surgical procedures in proposed MSAs and reduce MSA counter-highers.

The list of major medical centers has been published as part of the reference guide and also within the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP).

As a member of the National Alliance of Medicare Set-Aside Professionals, now the National MSP Network (MSPN), Tower has consistently advocated for the release of this list. We appreciate the efforts of MSPN leadership to pursue this with CMS management.

A big thank you to Steve Forry and John Jenkins at the CMS Division of MSP Program Operations and to the WCRC for their work to assemble and release this information for public use.

If you have any questions, please contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

NAMSAP Bulletin Highlights Meeting with CMS on Liability MSA Reviews

August 16, 2018

man holding transparent icons of people with stakeholder in the center

Recently, the National Alliance of Medicare Set-Aside Professionals (NAMSAP) released a Special Edition Bulletin providing insight into a meeting between CMS and NAMSAP representatives on the topic of the planned expansion of the Workers’ Compensation MSA review process to liability MSA Reviews. NAMSAP’s April 2018 meeting was one of several with stakeholder organizations.

Your writer was one of the NAMSAP representatives who had the privilege of meeting with CMS to hear and discuss how such a Liability MSA Reviews may work. Mr. Tom Stanley, the Co-Chair of NAMSAP’s Liability Committee provided a summary of the following meeting highlights in the bulletin:

CMS stated they have an 18-month timeframe (from April 2018) before it rolls out a LMSA Review program.
The program would be voluntary.
CMS has indicated that their enforcement mechanism is the denial of services.
CMS felt strongly that the injured party must receive something (free and clear) through settlement.
CMS would not review an LMSA until Settlement has been reached.
CMS feels a LMSA is exclusively the responsibility of the plaintiff.
Regarding LMSA’s, CMS made it clear that the defendant(s), and their insurers, are not a target.
Medicare pricing of services was discussed.
CMS does not feel it can mandate professional administration.
CMS would publish a LMSA Reference Guide.
Eligibility remains the same as the current WCMSA system – Medicare beneficiaries or injured parties who have a reasonable expectation of Medicare eligibility within 30 months. Per statute, Medicare’s interest must be considered in every claim.
A workload threshold of $250,000 is anticipated – “NO SAFE HARBOR”. This level mirrors the $25,000 workload threshold for WCMSA’s.
For settlements between $250,000 and $750,000 threshold, CMS approval is available and encouraged by CMS. CMS would apply “a formula” to determine the LMSA amount. Starting with the total settlement amount, CMS would subtract certain expenses and apply the discount factor to total settlement.
Above $750,000 level is a full commutation. A traditional MSA would be prepared and, if submitted to CMS, evaluated by CMS for adequacy.

As Mr. Stanley advised, “everything discussed in the meeting was subject to change and related to liability Medicare Set-Asides only.” I would like to emphasize that point as well. You should not in anyway take the above points as final, rather they are points of discussion as CMS continues to listen to stakeholders and assess the best method for protecting Medicare’s interests in post-liability settlement injury-related medical.

Importantly, CMS realizes that in protecting those interests an eventual voluntary LMSA review process must continue to provide an incentive for the parties to settle their case. Consequently, some type of apportionment to ensure the plaintiff receives a portion of the settlement monies is expected in any final review process.

NAMSAP will to continue to dialogue with CMS and also discuss with its membership, both through a webinar and at the annual conference, the points presented by CMS. Given the launch of a CMS LMSA review process is not expected for some time, Tower MSA Partners will shortly be releasing a white paper on best practices for addressing future medicals in liability settlements.

If you have any questions or would like to discuss the topic of LMSAs further, please contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or Daniel.anders@towermsa.com.

Related:

Liability Settlement Solutions

New CMS MSA Review Contractor: Different Name, Same Policy and Procedures

March 7, 2018

While the review contractor is changing, the Workers’ Compensation Medicare Set-Aside (WCMSA) review policies and procedures remain the same. This was the message related to attendees of the Workers Compensation Review Contractor (WCRC) transition webinar held by CMS, yesterday, March 7, 2018. The purpose of the webinar was to introduce the WCMSA community to the new WCRC and provide information on the transition from Provider Resources, which ceases its work on March 16, 2018, to Capitol Bridge, which commences its work on March 19, 2018.

John Jenkins, CMS’s Health Insurance Specialist overseeing the WCRC contract, led off the presentation and then turned it over to Holly Haven, Capitol Bridge’s WCRC Project Director. Ms. Havens provided the following key information:

What is Not Changing

As our program matures, we will strive to improve both the quality of our work and the timeliness in which cases are completed through automation and our continual improvement focus.

The review and decision making process will remain the same.

WCMSA proposals will continue to be submitted through the portal or by mail to the same Oklahoma City address.

All established timeframes remain the same.

All inquiries will be handled by staff in our Pittsford, NY office, and customer service will be a priority.

Inquiries may still be communicated via telephone.

In summary, Capitol Bridge will continue to be guided by the guidelines laid out in the CMS WCMSA Reference Guide and maintain the 20-business day turnaround time for review of a WCMSA as required by CMS.

What is Changing

Processing of all cases will be handled out of their facility in Pittsford, NY.
New phone number for the WCRC is (833) 295-3773 with customer service hours from 9am to 5pm EST.
Email address for the WCRC is WCRC@capitolbridgellc.com
Fax number is (585) 425-5390

In the Q&A session following the formal presentation additional information was provided:

WCMSAs will be reviewed by RNs with the MSCC credential.
The WCRC staff includes attorneys, physicians and pharmacists.
WCMSA proposals which have not been reviewed by the outgoing contractor by March 16 will be transferred to the new contractor for review.
In response to a question as whether to expect an MSA backlog such that review times will lengthen, CMS noted that the outgoing contractor was typically completing its reviews in less than the required timeframe of 20 days.The implication then is the new contractor may be using the full 20 business days to complete its review.
A question was raised regarding Liability MSAs, but no answer was given as the webinar was not for the purpose of addressing policy questions.

While the CMS WCMSA policy remains the same, the interpretation and implementation of that policy will soon be in new hands. Tower MSA will be closing monitoring WCMSA reviews through Capitol Bridge to ascertain what, if any, differences can be identified in the allocation of care in the WCMSA compared to the prior contractor. Variances outside of established CMS guidelines will be challenged.

If you have any questions, please contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or Daniel.anders@towermsa.com.

What Do Medicare Part D, Medicare Set-Asides and Parenting Have in Common?

March 2, 2018

parenting - father hugging two young children

For those who have raised children, or are in the process of doing so, one of our biggest challenges is to instill in our children some sort of positive decision-making paradigm in our children. You can call it religious values, moral absolutes, grounding, or just plain common sense, but as parents, we set boundaries (rules) from the earliest age, and try to be consistent in our enforcement. Our children may think we’re just mean, but this is a price we’re willing to pay if it helps establish an internal barometer to use when approached by people, thoughts and ideas that challenge them.

In raising my three children, one of the techniques I used was a simple, banded bracelet with the acronym, “WWJD” that is, What Would Jesus Do? This was a popular phrase in the Bible Belt where we lived. I asked that they look at the bracelet each time they were faced with an obstacle or asked to do something that didn’t quite feel right. One afternoon, my son was telling a story about something that happened at his elementary school that caused him to look at his bracelet. I was so pleased when he said he actually looked at it! He then responded, “Mom, I tried to decide what Jesus would do, but had a little bit of a tough time, so I switched it in my head to “WWMD”, and I knew exactly what Mom would do!” I couldn’t help laughing, but based on his response to the situation, my simple reinforcement worked. At the same time, this also reminded me that our actions speak much louder than our words….children will “do as we do” long before they will ”do as we say.”

How does this relate to Medicare Part D and Medicare Set Asides?

Each day, one of my first activities is to review my Google Alerts to look for news about NGHPs, Medicare Secondary Payer issues and opioids. This morning, the article that drew my attention was from MedPageToday.com entitled “CMS Proposes Opioid Prescribing Limits for Medicare Enrollees.” My first thought in reading the article was that this was great news.

“We are proposing important new actions to reduce seniors’ risk of being addicted to or overdoing it on opioids while still having access to important treatment options,” said Demetrios Kouzoukas, CMS deputy administrator and director of the Center for Medicare.

“We believe these actions will reduce the oversupply of opioids in our communities.”

Key components of the proposal include:

Hard formulary levels at pharmacies that would restrict the amount of opioids beneficiaries could receive
Establishment of a safety level of 90 morphine mg equivalent (MME)
Limiting the # of pills and days supply in an initial prescription for acute pain

According to Kouzoukas, “these are triggers … [that] can prompt conversations between physicians, patients, and plans about appropriate opioid use and prescribing.”

I then realized what CMS was doing. CMS was setting boundaries to help physicians, patients and plans make better decisions about opioid use…. the same type of boundaries I set for my children so they would make better decisions as adults. What a great idea! If physicians, patients and plans (both Medicare and workers’ compensation) can dialogue before Rxs are filled, better decisions about opioids are inevitable and the frequency of opioid addiction will diminish.

So what’s the problem?

Unfortunately, there remains a problem in the world of workers’ compensation and the WCMSA review process. While I applaud CMS’s effort, there remains a strong disconnect between CMS’s proactive stance on opioid limitations with Medicare Part D and its opioid-friendly review process for WCMSAs. At the same time, I must also admit to a similar disconnect between what happens with prescription opioids during the life of a workers’ compensation claim and what we are asking CMS to do when reviewing the MSA at settlement time. Are we asking CMS to “do as I say,” instead of providing the example of “do as I do?”

Can we ‘connect the dots’?

After reading the article, I realized that as an MSP compliance company that has integrated opioid triggers into its Pre-MSA Triage and review process since Day #1, Tower now has a new weapon in its arsenal to assist clients to identify pharmacy obstacles as early possible, and to address issues of inappropriate drug use. By advising clients to establish and enforce “CMS-like” boundaries at Rx fill time, we have the potential to reduce opioid use in workers’ compensation just as CMS seeks to accomplish with Medicare Part D. Through such efforts, we can reinforce dialogue between physicians, claimants and workers’ compensation plans before the Rx is filled, and hopefully facilitate better decisions about the first opioid Rx.

And as for the disconnect between Medicare Part D and the WCMSA review process, we cannot force CMS to change its WCMSA prescription drug review process. We can, however, leverage CMS’s expertise to support better outcomes with Medicare beneficiaries, MSAs and settlements by mirroring their Medicare Part D policies and processes within the workers’ compensation PBM model. In doing so, we provide CMS with a positive example of their own recommendations implemented successfully, and can hopefully encourage them to “do as we do.”

Conclusion

So how do we affect change in opioid prescribing habits in workers’ compensation? It’s as simple as the bracelet I gave my children. From Day #1 of a claim involving an active or soon to be active Medicare beneficiary, we continually ask the question, “What Would Medicare Do?” and we execute.

CMS Statement on Opioids and WCMSAs Provides Little Clarity as to Future Review Practices

December 27, 2017

In a recent post on its website, the Centers for Medicare and Medicaid Services (CMS) acknowledged the opioid crisis in this country, but provided little clarity as to how it intends to address this crisis in its review and approval of Workers’ Compensation Medicare Set-Asides (WCMSAs).

The 12/14/2017 statement provides as follows:

CMS understands the concerns regarding the opioid crisis occurring in the United States. We are committed to ensuring the determination of Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) amounts are an adequate projection of claimant’s needs for future medical services and prescription drugs. CMS continually evaluates all policies and procedures related to WCMSA amounts. Any changes that Medicare pursues related to this issue will be reflected in our WCMSA amount review process.

More information on the WCMSA process can be found in the WCMSA Reference Guide.

We assume the above statement may be, in part, related to the California Workers Compensation Institute (CWCI) study finding nearly 70% of CMS approved MSAs require funding of opioids over an injured worker’s life expectancy (See our article, Opioids in the MSA . . . Challenges and Strategies, where this study is discussed). While we credit CMS’s Office of Financial Management (the CMS department which oversees the WCMSA review program and contractor) with recognizing the opioid crisis, what is left uncertain is what specific actions CMS is to take to address this problem in WCMSAs. Instead, CMS provides a vague statement indicating any changes related to the opioid issue will be reflected in its WCMSA review process and then cites its WCMSA Reference Guide.

CMS does not cite to a particular section of the guide, but we assume the following would be the most pertinent:

Drug Weaning/Tapering

Drug weaning commonly occurs with pain medications, such as opioids, especially when claimants’ work injuries improve. The WCRC takes all evidence of drug weaning into account, although in most circumstances the WCRC cannot assume that the weaning process will be successful. Usually, the latest weaned dosage is extrapolated for the life expectancy, but again, they assess all records when making these types of determinations. Where a treating physician believes tapering is possible and in the best interests of the claimant, CMS will consider all evidence in making a WCMSA determination, including medical evidence of current actual tapering.

Based upon the Tower MSA CMS Reconciliation Module, which reviews all MSA determinations for the purpose of identifying trends in CMS WCMSA allocation practices, CMS consistently disregards any active weaning or tapering process or scheduled reduction to future medication use and instead takes the latest dosage found in the medical records and/or prescription history and extrapolates it over the claimant’s life expectancy.

The question then is whether this December 2017 statement signals a departure by CMS from these past practices to a policy which will now give more weight to a weaning or tapering schedule from the treating physician which translates into limitations on the allocation of opioids in the WCMSA. We will take a wait and see approach in this regard.

It should be understood though that even were CMS to limit the allocation of opioids in the WCMSA, this in no way prevents the claimant from using the WCMSA funds for filling opioid prescriptions in excess of what is allocated. The reason being is CMS rules for administering a WCMSA allow for the funds in the account to be used for any Medicare-covered injury-related treatment or medication. As such, with a valid prescription, there is nothing to stop a claimant from converting funds allocated to a surgery to pay for medications, including opioids. It will remain then in the hands of the claimant’s medical provider to wean the claimant off opioids and other medications not intended for long-term use.

Practical Implications

As always, we will monitor CMS WCMSA determinations for signs of any changes to their allocating practices for prescription medications, especially in regard to opioids. However, we have to assume that until we see any changes, CMS will continue to follow its policy of taking the most recent medication dosage and frequency and pricing it out over the claimant’s life expectancy.

What this means then is opioid misuse must be addressed prior to submission of a WCMSA to CMS with any actual elimination of opioids documented in the medical records prior to submission of the MSA. Tower MSA is committed to working with our clients on reduction and elimination of opioids prior to CMS submission. Our Pre-MSA triage service is uniquely designed to identify such MSA cost-drivers and recommend intervention strategies, including escalating the matter to our Internal Pharm. D. for direct contact with the treating physician. Resulting reductions in opioid use limit MSA costs to the employer and provide for a healthier injured worker over his or her lifetime.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding CMS practices in allocation of prescription medications in the WCMSA.

CMS Releases Statement Regarding Stakeholder Input in Liability MSA Review Process

October 27, 2017

CMS issued the following brief statement on their website this week:

The Centers for Medicare and Medicaid Services (CMS) continues to consider expanding its voluntary Medicare Set-Aside Arrangements (MSA) review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS will work closely with the stakeholder community to identify how best to implement this potential expansion of voluntary MSA reviews. Please continue to monitor this website for updates and announcements of town hall meetings in the near future.

Notably, very little information provided other than stating CMS will work with stakeholders before formalizing the expansion of the MSA review process to liability and no-fault. Based upon this statement, we can assume CMS will not spring the expansion on us, but give impacted parties an opportunity to comment before a final policy is put in place. Tower MSA will provide updates when further information is released by CMS or town hall meetings are scheduled.

New Commercial Repayment Center Contractor on the Horizon; WCRC Contract Protested

October 9, 2017

A recent press release from the Performant Financial Corporation announced it has been awarded the Commercial Repayment Center (CRC) contract by the Centers for Medicare and Medicaid Services (CMS). Barring a bid protest, we expect a transition to the new CRC contractor over the next few months (CGI Federal’s contract, the outgoing CRC contractor, appears to run through 1/8/2018).

CRC Responsibilities

The Commercial Repayment Center is responsible for identifying and recovering primary payments mistakenly made by the Medicare program when another entity had primary payment responsibility (otherwise known as conditional payments). While CGI Federal has had the responsibility for recovering from group health plans for several years, it has been recovering from non-group health plans, such as a liability insurer, no-fault insurer, or workers’ compensation entity, only since 10/1/2015.

As those of you who have had any dealing with the CRC know, communication with the CRC following that start date was often frustrating as a result of long turnaround times to receive conditional payment information and inconsistent and contradictory responses from CRC representatives. While communication with the CRC has definitely improved over time, CMS has nonetheless chosen not to renew their contract with CGI Federal. CMS’s reasons are unstated, but as we noted in a recent article, CMS Releases Annual Report on CRC Conditional Payment Recovery, conditional payment amounts recovered by the CRC on behalf of Medicare declined from 2015 to 2016, despite the expansion of CRC’s recovery efforts to non-group health plans.

Besides the CRC contract, Performant currently acts as a Recovery Audit Contractor (RAC) for Medicare’s fee-for-service program (Parts A and B). As a RAC, Performant identifies and corrects improper payments made to medical providers as a result of insufficient documentation to support the payment, payments made which do not meet CMS guidelines and payments made for services that are incorrectly coded.

Similar to the RAC contract, the CRC contract is paid on a contingency basis. Consequently, the CRC contractor has an incentive to recover as much as possible on behalf of CMS. Per the Performant press release, “at full scale, Performant anticipates staffing the program with over 250 dedicated employees operating out of Performant’s offices around the country.”

CMS contractor transitions (see below bid protest) usually do not go as smoothly as advertised, thus we will wait and see how effectively this new contractor takes on the role as the CRC. We will advise you of any important developments during to and subsequent to the contractor transition.

WCRC Contract Under Protest

In a 9/11/2017 article, CMS to Transition to New MSA Review Contractor, we detailed the awarding of the new $60 million, five-year contract, for the Workers Compensation Review Center (WCRC) to Capitol Bridge, LLC. Two of the unsuccessful bidders, Arch Systems, and Ken Consulting, have filed formal protests to the awarding of the contract to Capitol Bridge. The protests are to be resolved by 12/21/2017. It appears then that this will delay the transition to the new WCRC. We will keep you apprised of any notable news on the WCRC transition.

CMS to Transition to New MSA Review Contractor

September 11, 2017

On September 1, 2017, the Centers for Medicare and Medicaid Services (CMS) announced the awarding of the contract for the Workers Compensation Review Contractor (WCRC) to Capitol Bridge, LLC. The $60 million contract is for one-year with the option of renewing for an additional four years.

Since 2003, CMS has had in place the WCRC for the purpose of reviewing Workers’ Compensation Medicare Set-Aside (WCMSA) proposals submitted to CMS for review and approval. The WCRC evaluates these proposals and provides a recommendation to the designated CMS Regional Office (RO) as to whether the proposed MSA amount adequately protects Medicare’s interests. If the WCRC disagrees with the proposal it will provide an alternate recommendation, either higher or lower, than the proposed amount. The CMS RO usually accepts the recommendation from the WCRC and issues the approval letter to the submitter of the proposed MSA.

Provider Resources, Inc., has been the WCRC for the past five years. It is unclear based upon the available information when Capitol Bridge will take over from Provider Resources, although the solicitation for the WCRC contract provided for a three-month transition period.

Tower MSA Takeaways

It is important to note that while the review contractor may change, the policies in place to review WCMSAs are set by CMS, not the contractor. Consequently, we do not anticipate any significant change to how WCMSAs are reviewed and approved under the new contractor. Nonetheless, there are some recent changes to the WCMSA Reference Guide, such as the Amended Review process, which will fall largely on Capitol Bridge to implement (See article: Practical Implications of the Revised CMS WCMSA Reference Guide). Also, as we advised in another article, CMS MSA Review Expansion to Liability Planned for 2018, the new WCRC contract provides for an optional expansion of the WCMSA review process to liability claims as of 7/1/2018. At this time, it is uncertain whether CMS will choose to move forward with such an expansion as of that date.

Given our experience with other CMS contractor transitions we anticipate the new contractor will have a learning curve, which may result in longer turnaround times for MSA submissions and some responses inconsistent with the prior contractor’s reviews. Tower MSA will, if necessary, address with CMS any WCMSA approval falling outside of established CMS guidelines.

We look forward to working with Capitol Bridge over the coming months and years to provide for an effective WCMSA review and approval process that benefits all interested parties. Tower MSA will continue to provide any relevant updates as Capitol Bridge transitions to its role as the WCRC.