CMS Implements WCMSA Reporting and Eliminates Amended Review Wait Time

April 10, 2025

Person reviewing WCMSA report with a magnifying glass.

CMS is implementing important changes that impact how workers’ compensation Medicare Set-Aside (WCMSA) amounts are reported and how Amended Reviews are managed. These updates are outlined in the latest revisions to CMS’s user and reference guides.

Key Updates and Important Dates

  • Effective April 4, 2025:
    CMS has begun requiring Section 111 reporting for workers’ compensation MSAs for TPOC dates of April 4, 2025 and later. All relevant guides now reflect the updated WCMSA reporting requirements tied to this start date.
  • Elimination of the One-Year Waiting Period:
    Previously, once an MSA was approved, a waiting period of one year was required before an Amended Review could be submitted. With the new changes, an Amended Review MSA can now be submitted at any time after approval as long as the other criteria are met.

What’s New in the CMS Guides?

Section 111 Mandatory Insurer Reporting User Guide (Version 8.0)

  • Updated Field Numbers:

Field numbers have been updated throughout the user guide to align with the WCMSA reporting requirement effective April 4, 2025.

  • Clarification on Reporting Thresholds:

In Chapter IV, under Technical Information (Section 6.4 – TPOC Reporting), the guide now clearly states that the $750 reporting threshold applies to non-trauma (alleged ingestion, implantation or exposure incident) no-fault as well as workers’ compensation cases.

  • Additional MSA Correction Scenarios:

Three new scenarios have been added to the event table in Section 6.6.4. These are specific to errors or corrections linked to WCMSA reporting.

  • Enhanced Appendices:
  • The guide’s Appendices A, B, and G include updated reporting requirements. Notably, ZIP+4 guidance has been improved. Additionally, effective October 6, 2025, if an agent’s name is provided in the submission, the Recovery Agent TIN field is now mandatory.

WCMSA Reference Guide (Version 4.3)

  • Settlement Notification Updates:
    A “Notice of Settlement Received” letter has been introduced in Appendix 5. Whenever a WCMSA is reported, CMS will issue this letter to the claimant. This requirement applies even to MSAs that are not CMS-approved, ensuring that all claimants receive appropriate notification and that annual attestations are submitted for documented expenditures.
  • Streamlined Amended Review Process:
    Along with removing the one-year wait, Sections 16.3 and 19.4 now clarify that the change of submitter policy applies to Amended Review MSAs as well. This allows for greater flexibility in managing and updating MSAs after they have been approved. See Tower article here on Amended Reviews.

WCMSA Self Administration Toolkit (Version 1.7)

  • Reference-Only Guidance:
    The toolkit now clearly states that it is a reference manual—not an exhaustive step-by-step guide—to assist users with WCMSA administration.
  • WCMSA Basics Introduction:
    A new section introduces the fundamentals of WCMSA administration, making it easier for users to understand the process from the beginning.
  • Portal Access Instructions:
    Detailed instructions and a screenshot now guide users on how to access the WCMSA portal on Medicare.gov for submitting their annual attestation.
  • Removal of the Inheritance Section:
    The previously included section on what happens to the MSA funds after the Medicare beneficiary’s death has been removed. It is unclear why this was removed as it provided instructions on how the MSA funds are to be handled after the Medicare beneficiary dies (There remain instructions in Section 19.2 of the WCMSA Reference Guide on what happens to the MSA funds post-death).

Questions or More Information?

For any questions regarding these updates or for further assistance, you can reach out to Tower MSA Partners’ Chief Compliance Officer, Dan Anders, at 888.331.4941 or via email at daniel.anders@towermsa.com.

 

How Does a Workers’ Compensation MSA Work?

April 1, 2025

Tower MSA Partners banner with copy that reads “How does an MSA work” with a button that says find out and a hand touching papers with a calculator, stethoscope, and medication by it.

Second Installment in Our Tower MSA Partners Series

At Tower MSA Partners, we understand that navigating a Workers’ Compensation Medicare Set-Aside (WCMSA) can seem complex. It is an unavoidable complexity as the Medicare Secondary Payer Act provides that medical expenses related to a workers’ compensation injury cannot be shifted onto the Medicare program.  In this installment, we break down the process into clear, actionable steps—from determining the amount of an MSA to securing the Centers for Medicare & Medicaid Services (CMS) approval and finally funding the account. Let’s walk through each stage.

Determine the WCMSA Amount

This consists of a medical and legal review of relevant claim documents by your MSA partner to determine the appropriate amount to fund the account:

  • Medical History Review:
    A thorough review of the injured worker’s medical records, treatment plans, and projected future medical treatments, including surgeries, and DME is conducted. This detailed analysis helps estimate the expenses that Medicare would potentially cover over the worker’s lifetime.
  • Legal History Review:
    If a $0 MSA is indicated or there are other bases to support an exclusion of diagnosis or treatments for legal reasons, then a legal history review is also completed. Such a review identifies valid support for limiting the MSA amount under state statutes.
  • Accuracy and Mitigation Opportunities:
    The MSA should accurately reflect reasonably probable future medical care. Often, outdated and open-ended medical records and prescription histories result in unnecessary treatment and medications being added to the MSA. Your MSA partner should identify opportunities for mitigation and contact the treating physicians to clarify ongoing and future medical care.
  • MSA Report:
    The comprehensive MSA report, prepared by your MSA partner provides the expected lifetime medical costs. The report should indicate the MSA calculated as a lump sum and as a structure (seed MSA amount and annual payments), so the parties have both options available.  This report is an integral part of the submission to CMS, if needed, demonstrating that the WCMSA is properly funded.

By accurately determining the WCMSA amount, you ensure that the injured worker’s future healthcare needs are met without jeopardizing compliance.

CMS Review and Approval

After establishing the WCMSA amount, the next critical phase involves submitting the proposal for CMS review, if needed:

  • Submission for CMS Approval:
    CMS MSA review and approval is voluntary, but recommended in most cases, when the injured worker is a Medicare beneficiary, and the estimated settlement exceeds $25,000 or when the injured worker has a reasonable expectation of Medicare eligibility within the next 30 months and the estimated settlement exceeds $250,000.  Work with your MSA partner to obtain the claimant executed Consent to Release form and answer required submission questions, such as estimated settlement amount, how the MSA will be funded (lump sum or annuity) and administered (See below). Once your calculations and documentation are in order, the WCMSA proposal can be submitted to CMS. This formal submission initiates the review process.
  • Review Process:
    CMS will evaluate the proposal to confirm that the WCMSA is necessary and that the funding is sufficient. This includes verifying the documentation and ensuring that all criteria are met.
  • CMS Determination:
    Upon successful review, CMS will issue a Determination Letter stating the approved WCMSA amount. CMS can approve the MSA as submitted or issue a counter-higher or lower.  This letter is critical, as it validates that the MSA is sufficient to consider Medicare’s interests such that if the funds were to run out Medicare would step in and pay for injury-related medical expenses.

A smooth review process is achieved by meticulous preparation and prompt responses to any CMS queries.

Fund and Administer the WCMSA

The final step is to properly fund and administer the WCMSA according to strict regulatory guidelines:

  • MSA Administration: Depending on what the injured worker agrees to, he or she can either choose to self-administer the MSA funds or have a third party MSA professional administration company administer the funds.
  • Dedicated Interest-Bearing Account:
    The approved WCMSA funds must be placed in a dedicated, interest-bearing account.
  • Purpose-Bound Use:
    Funds in the WCMSA account must be used exclusively for medical expenses related to the workers’ compensation claim that Medicare would otherwise cover. This ensures that the funds remain available for their intended purpose.
  • Ongoing Compliance:
    If self-administered, the beneficiary must submit an annual attestation confirming the proper use of the funds. Professional administration may involve additional oversight, such as periodic deposits and considerations for fund reversion.

Proper funding of the WCMSA not only fulfills CMS requirements but also secures the injured worker’s future medical care.

Conclusion

Navigating a Workers’ Compensation Medicare Set-Aside is a detailed process that involves assessing the need, determining the correct funding amount, securing CMS approval, and ensuring proper fund management. At Tower MSA Partners, our commitment is to guide you through every step, ensuring that your WCMSA complies with all regulatory standards while safeguarding the healthcare needs of injured workers.

For more insights or assistance with your WCMSA process, feel free to reach out to our team. Stay tuned for our next installment, where we explore guidelines for determining when an MSA is required and best practices for compliance.

CMS 2024 WCMSA Metrics: Key Trends in Medication and Treatment Costs

December 4, 2024

stethoscope and pill bottle on representing WCMSA trends

CMS 2024 WCMSA Metrics: Key Insights into Costs and Trends

The Centers for Medicare and Medicaid Services (CMS) has released its 2024 data on Workers’ Compensation Medicare Set-Aside (WCMSA) reviews. This year’s metrics highlight two significant trends: declining prescription drug costs and rising medical treatment costs.

For employers, insurers, and other stakeholders, understanding these trends is crucial for effective planning and cost management. Here’s a breakdown of the key findings and how Tower MSA stands out in the industry.

CMS WCMSA Metrics Overview: 2020–2024

CMS’s fiscal year 2024 data provides a five-year perspective on MSA reviews, comparing proposed amounts to CMS-recommended (approved) amounts. Here are the major takeaways:

  • Consistency in Review Numbers:
    CMS completed 14,862 MSA recommendations in 2024, closely aligning with the five-year average of 15,138.
  • Decrease in Recommendations:
    After a 9% rise in recommended amounts between 2022 and 2023, 2024 saw a 6% drop.
  • Stable Average MSA Amounts:
    The average approved MSA decreased slightly to $85,927 in 2024 from $86,453 in 2023. However, this remains above the five-year average of $83,851.
  • Variance Between Proposed and Approved Amounts:
    The variance, which increased to 22% in 2023, remained steady at 21% in 2024.

Key Trends in Costs

  1. Prescription Drug Costs Continue to Decline

CMS data reveals a notable 33% decrease in average prescription drug costs over five years, from $26,574 in 2020 to $17,807 in 2024. This decline reflects:

  • Reduced opioid use in workers’ compensation cases.
  • Increased allocation of generic medications over brand-name drugs.
  1. Treatment Costs Are Rising

While prescription costs have fallen, the average treatment costs have increased by 15% since 2020, signaling a shift in the cost structure for MSAs.

How Tower MSA Partners Compares to Industry Averages

Tower MSA Partners has consistently achieved lower costs for its clients, significantly outperforming industry averages in both total MSA and prescription drug components.

  • Average Approved MSA (2020-2023):
    • CMS: $82,332
    • Tower: $63,005 (23% lower)
  • Prescription Drug Component (2020-2023):
    • CMS: $22,048
    • Tower: $14,286 (35% lower)

Through targeted interventions like our Physician Follow-up service, Tower mitigates costs while ensuring compliance with CMS requirements.

Why CMS Metrics Matter

These annual metrics provide invaluable insights for stakeholders managing workers’ compensation cases. They not only reflect trends in CMS review processes but also offer benchmarks to evaluate cost-saving strategies.

Tower MSA’s cost-effective approach demonstrates that significant savings are possible with a robust review and allocation methodology.

Have Questions? Let’s Connect

If you want to learn more about how CMS metrics impact your workers’ compensation program—or explore cost-saving opportunities—contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or call 888.331.4941.

Top 5 Most Listened to Podcast Episode: Medicare Set Asides

November 20, 2024

image of microphone representing medicare set aside podcast

Medicare Set Aside Podcast Featured

We are delighted to announce that our very own Dan Anders, Chief Compliance Officer at Tower MSA Partners, has been featured in the Top 5 Most Listened to Episodes of Berkley Industrial Comp’s Adjusted Podcast!

The Adjusted Podcast recently reached its milestone 100th episode and is celebrating by highlighting its top episodes. Dan’s insightful discussion on Medicare Set Asides has made the list.

Listen to Dan’s episode here: Medicare Set Asides with Dan Anders

In this popular episode, Dan dives deep into the complexities of Medicare Set Asides, offering valuable guidance and expertise that have resonated with professionals across the workers’ compensation industry.

We are incredibly proud of Dan’s contribution and grateful to all the listeners who have made this recognition possible. Your support helps us continue our mission to provide clarity and solutions in the ever-evolving world of Medicare compliance.

Join us in congratulating Dan and the Adjusted Podcast team on this remarkable achievement! Let’s continue to engage, learn, and grow together in the workers’ compensation community.

Subscribe to our blog for more insights and updates from Tower MSA Partners.

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

March 7, 2018

logo for cms

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 Webinar to Introduce New MSA Review Contractor

March 1, 2018

logo for cms

Effective March 19, 2018, Capitol Bridge, LLC will be taking over responsibilities from Provider Resources as CMS’s Workers Compensation Review Contractor (WCRC). CMS has now announced a webinar set for Wednesday, March 7, 2018 at 1:00 PM ET to introduce the new MSA review contractor. See CMS Notice which includes a link to register for the webinar.

Capitol Bridge becomes the third company since 2003 to be awarded the WCRC contract. The contractor is charged with evaluating Workers’ Compensation Medicare Set-Aside (WCMSA) proposals submitted to CMS for review and approval. Using criteria set by CMS, it makes recommendations 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 MSA.

Besides the transition to the new contractor, what is unique about Capitol Bridge’s contract with CMS is the inclusion of a provision providing for the optional expansion of its MSA review responsibilities to liability and no-fault cases as early as July 1, 2018. We caution though that CMS has not announced that such an expansion will occur on July 1, 2018.

Tower MSA applauds CMS for inviting those impacted by the contractor change to this introductory webinar. On the heels of the January webinar introducing the new CRC contractor, we are pleased with more transparency by CMS in its process and policy changes. If you are unable to attend CMS’s webinar, Tower MSA will provide a summary of relevant information on our MSP Compliance Blog following the presentation.

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.

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.