Tag Archives: CMS

Prescription Medication Updates That May Affect Your Medicare Set-Aside

We continually monitor pricing of the most common medications seen in Workers’ Compensation Medicare Set-Aides (WCMSAs) in order to identify pricing changes affecting MSAs positively. The month of December brought a price drop for gabapentin 800mg tablets commonly used to treat neuropathic pain.

Below is the product confirmed to have a reduced AWP and confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product name NDC Code Dosage form Strength AWP unit price reduction
Gabapentin 00904-6586-61 TAB 800 mg $2.16

Please note RED BOOK® AWP (Average wholesale price) is subject to change and this pricing is subject to an increase or decrease in the future.  

CMS will utilize the lowest AWP published by RED BOOK when reviewing a WCMSA, therefore the lower pricing of these medications will immediately impact the prescription costs for WCMSAs (both present as well as prior WCMSAs that have not settled and there is no CMS determination issued) where these drugs are prescribed.

It is our recommendation carriers, TPAs and claim handlers review cases where the above noted medication is prescribed to determine the benefit from decreased cost. We will proactively reach out to our clients in reference to previously completed WCMSA’s where this medication was prescribed and  continue to monitor future portal changes and generic equivalents introduced to the market in order to keep the industry informed.

CMS Releases NGHP Section 111 User Guide v5.2

CMS has released an updated NGHP User Guide, version number 5.2. The update clarifies MIR Section 111 reporting thresholds initially addressed in a published alert by CMS Financial Services Group posted to the Non-Group Health Plan Recovery site on November 15, 2016 entitled “2017 Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards or Other Payments”. The changes to thresholds are summarized below.

For Section 111 reporting, the Centers for Medicare & Medicaid Services (CMS) has changed the minimum reportable Total Payment Obligation to the Claimant (TPOC) amounts for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claims.

  • Liability is changing from $1000 to $750 for TPOC Dates of 1/1/2017 and subsequent.
  • No-Fault is changing from $0 to $750 for TPOC Dates of 10/1/2016 and subsequent.
  • Workers’ Compensation (WC) is changing from $300 to $750 for TPOC Dates of 10/1/2016 and subsequent.

TPOC amounts exceeding these thresholds must be reported. However, TPOC amounts less than the specified threshold may be reported and will be accepted.

The logic for the CJ07 error has been changed such that a TPOC of any amount will be accepted for all types of TPOCs, including liability TPOCs. The CJ07 error will continue to be returned for a liability, workers’ compensation, or no-fault claim report where the ORM Indicator is set to “N” and the cumulative TPOC amount is zero.

We are able to provide a consolidated PDF file of all the updated chapters upon request. Please contact us at JustRegister@optum.com if you would like to receive this consolidated, searchable file. For more information, please email JustRegister@optum.com.

Bid for WCRC with LMSA Capabilities Delayed by CMS

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) solicited bids in an RFP for a Workers’ Compensation Review Contractor (WCRC) to review workers’ compensation Medicare Set Aside (WCMSA) proposals, which potentially include liability Medicare Set Asides (LMSAs). The bid was to be released on September 22, 2016, but has been delayed. When this deadline passed without the release of the solicitation, we were notified of the delay. CMS has postponed the award date and now anticipates releasing the bid sometime during the first quarter of fiscal year 2017, pending availability of funds. However, the dates are subject to change.

Although not certain, it is anticipated that guidelines for review of LMSAs or modifications to current WCMSA review thresholds will be shared prior to release of the solicitation. While we remain alert to potential changes in the future, our present services continue without change. Upon release of the bid and identification of WCMSA contractor, there are a few potential areas of consideration:

  • A new WCMSA contractor may delay MSA approval times
  • A new WCMSA contractor may result in inconsistencies in acceptance of what is allocated
  • Either the same or a new WCMSA contractor who is trained for LMSAs may result in inconsistencies and delays
  • The same WCMSA contractor may add LMSA reviewers for new guidelines which may result in inconsistencies and delays

If LMSAs are included in the responsibilities of the WCRC, guidelines for LMSAs are expected to be released. Guidelines will review threshold amounts and share an apportioning formula for use for both the extent of liability and the extent of injuries based upon a ceiling of policy limits. They are also expected to include total settlement amount, judgment rendered or arbitration amount awarded. In the meantime, efforts to equitably influence the LMSA guidelines are anticipated from CMS.

We expect further communication from the CMS in the coming months. Our teams remain engaged with these changes and will share information with you as it becomes available.

Major Changes to Conditional Payment Reimbursement Process for Entities that Have Accepted ORM

Article by Rafael Gonzalez, Esq. Vice President, Strategic Solutions HELIOS Settlement Solutions

Article by
Rafael Gonzalez, Esq.
Vice President, Strategic Solutions
HELIOS Settlement Solutions

iStock_000003223396XSmall_webAs those of you who follow us regularly on this blog know, on August 5, 2015, we anticipated that after the Center for Medicare and Medicaid Services (CMS)’ announcement of the transition to the Commercial Repayment  Center (CRC) for reimbursement of conditional payments (CP) directly from applicable plans (AP) who have accepted ongoing responsibility for medical (ORM), there would be major changes coming to the conditional payment resolution process. Sure enough, on August 25, 2015, CMS held a webinar to inform stakeholders on the new role of the CRC in the Non-Group Health Plan (NGHP) conditional payment recovery process.

In keeping with their July 1, 2015, and July 29, 2015 announcements, CMS again indicated that “as part of CMS’ continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, CMS will be transitioning a portion of the NGHP recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its CRC.” During the webinar, CMS announced that “effective October 5, 2015, the CRC will assume responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity (LNFWC) as the identified debtor.  In other words, the CRC will identify and validate recoverable conditional payments, issue conditional payment notices (CPNs) and demand letters, respond to disputes and appeals, receive payments and resolve outstanding debts, and refer delinquents debts to the Department of Treasury (DOT) for further collection actions.”

At the 8/25/15 webinar, CMS indicated that the BCRC will continue to maintain responsibility for “all data collection activity, including Mandatory Insurer Reporting (MIR) information. It will also continue to pursue recovery from the beneficiary directly and continue to seek recovery on cases that initiated prior to October 5, 2015 where an AP is the identified debtor. Therefore, the BCRC will continue to provide conditional payment letters (CPLs) when a beneficiary self reports that a LNFWC entity has primary payment responsibility for an illness, incident, or injury where Medicare has made a conditional payment. Such CPLs will include conditional payments on a Payment Summary Form,  will explain how to dispute payments made by Medicare, and will advise the AP how to move the recovery to final demand.”

In contrast, CMS also informed that “the CRC will be the one issuing CPNs when LNFWC entities indicate through MIR that it has ORM. The CPN will include conditional payment information on a Statement of Reimbursement (SOR) with items or services paid by Medicare it seeks to recover, will  explain how to dispute any item or service included in the SOR, and will advise insurers and entities what further actions need to be taken.”

During the webinar, CMS made it clear that “both CPLs and CPNs are not requests for payment. They are information provided to the LNFWC entity for an opportunity to ensure an accurate listing of conditional payments. Therefore, if an AP believes a medical claim should be removed from the CPL or CPN, a dispute may be filed with proper documentation to challenge such payment. A major difference between CPLs and CPNs however is that although there is no time limitation when responding to a CPL, the LNFWC entity must file the dispute within 30 days of the CPN date.”

Yes, you read that right! If the CRC sends a LNFWC entity a CPN seeking reimbursement for conditional payments Medicare believes to be related to the accident, incident, or injury, the AP has 30 days from the date of the CPN to respond or dispute such payments. “The AP may file a dispute by contacting the CRC in writing or through the Medicare Secondary Payer Recovery Portal (MSPRP). Disputes submitted to the CRC via the portal may only be submitted on the basis of relatedness and in response to a CPN; all other disputes must be submitted in writing. Yes, that means that if the LNFWC entity has more than one dispute in the same case, for example relatedness to the case and claims paid to the provider, the dispute must be submitted in writing, not through the portal.”

During the webinar CMS also clarified that upon filing a dispute, the CRC will review and evaluate the dispute. The CRC has the authority to remove any medical claim from the SOR if the CRC agrees with the LNFWC entity that such payment is not related to the claim at hand, or to the condition related to the claim at hand. “Any medical claim that remains in the SOR will then be included in the demand letter (DL). Any new medical claim that may have been received during the dispute and review process will also be added to the recovery amount and included in the DL.”

CMS also indicated at the webinar that if no dispute is received following a CPN, or if after dispute, the SOR contains one or more medical claims Medicare believes to be due, the CRC will issue a DL to the AP. The DL will include “basic information regarding the case, an updated SOR with a final listing of the items or services Medicare expects reimbursed, and an explanation of how to appeal any items and or services the LNFWC entity believes should be removed from the SOR.”

As we blogged on April 24, 2015, as a result of the Strengthening Medicare and Repaying Taxpayers (SMART) Act, LNFWC entities are now afforded a formal multilevel appeal process. It includes an “initial determination” (the MSP recovery demand letter), a “redetermination” by the contractor issuing the recovery demand, a “reconsideration” by a Qualified Independent Contractor (QIP), a hearing by an administrative law judge (ALJ), a review by the Departmental Appeals Board’s Medicare Appeals Council (MAC), and judicial review. Therefore, if after dispute, a LNFWC entity still believes an item should be removed from the SOR, then such AP may appeal same using this process.

As a result of technical difficulties throughout the presentation and not being able to answer all of the questions, issues, and concerns from those attending, CMS concluded the webinar by indicating it will hold another webinar on September 17, 2015.

Considering these significant changes, their potential impact on your claims, and effect on your bottom line, if you haven’t already, this is a perfect time to make sure that your Mandatory Insurer Reporting data is accurate, that your ORM process is working smoothly, that your transition to ICD-10 is on track, and that your MSP vendor is ready for these changes. Now more than ever, all liability insurers, self insured, no-fault insurers, and workers compensation entities must prepare themselves for a new conditional payment reimbursement world, a world in which if such applicable plan has accepted ongoing responsibility for medical, Medicare will no longer wait for settlement, judgment or award to seek reimbursement of conditional payments made related to the claim, but will seek reimbursement, possibly more than once, while the claim is still open. Whether such conditional payments exist before or after October 5, 2015, Helios Settlement Solutions is prepared to assist clients communicating, disputing, and appealing such conditional payments with the Commercial Recovery Center, as well as the Benefits Coordination Recovery Center. As we have been doing successfully for years, our Conditional Payments Resolution team is ready to continue to help clients with cases where CMS is pursuing recovery from the self insured, liability insurer, no-fault insurer or WC entity directly.  As always, we will continue to monitor these issues and be sure to report on any changes, including items discussed in CMS’ planned September 17, 2015 webinar.