On March 29, 2013, CMSCenters for Medicare and Medicaid Services issued its first ever WCMSAWorkers' Compensation Medicare Set-Aside Reference Guide. To view and download a copy of the guide, please click here.
At the beginning of this 88 page guide, CMSCenters for Medicare and Medicaid Services states that the guide was written to “. . . help you understand CMSCenters for Medicare and Medicaid Services’ Workers’ Compensation Medicare Set-Aside Arrangement amount approval process and to serve as a reference for those electing to submit such proposals to CMSCenters for Medicare and Medicaid Services for approval.”
The guide appears to reflect information compiled from previously issued WCMSAWorkers' Compensation Medicare Set-Aside Regional Office Memorandums issued by CMSCenters for Medicare and Medicaid Services, and information provided on the CMSCenters for Medicare and Medicaid Services WCMSAWorkers' Compensation Medicare Set-Aside website. Therefore, the vast majority of the information contained within the guide is not new and rather is more of a compilation of previously issued guidance into one document.
However, PMSI has noted a few minor interesting items included within the WCMSAWorkers' Compensation Medicare Set-Aside Reference guide:
WCMSAWorkers' Compensation Medicare Set-Aside Portal: CMSCenters for Medicare and Medicaid Services has included information relevant to the online WCMSAPWorkers' Compensation Medicare Set-Aside Portal online portal. This portal is not new and has existed since November of 2011; however, it appears to be the first time in which CMSCenters for Medicare and Medicaid Services has issued formal guidance around the portal since it was initially introduced (see section 9.1 for more information on the WCMSAWorkers' Compensation Medicare Set-Aside portal).
List of WCRCWorkers’ Compensation Review Contractor Review Reference Tools: CMSCenters for Medicare and Medicaid Services has provided a list of review reference tools used by the WCRCWorkers’ Compensation Review Contractor (the WCRCWorkers’ Compensation Review Contractor is instructed to utilize these tools when reviewing a proposed WCMSAWorkers' Compensation Medicare Set-Aside). While a list of the reference tools is helpful, one of the items that would have been very beneficial to have been included within this guide would be an updated set of Operating Rules (see top of page 44). The last time these Operating Rules were updated was April 22, 2010, and they were published under the prior WCRCWorkers’ Compensation Review Contractor contractor. Therefore, an updated set of Operating Rules would provide insight as to how the new WCRCWorkers’ Compensation Review Contractor contractor might review WCMSAs differently than the prior contractor. This would be great assistance to submitters of WCMSAs currently trying to track the allocating trends of the new contractor.
WCMSAs not meeting CMSCenters for Medicare and Medicaid Services Review Threshold: The guide states that “. . . if an individual’s WC settlement does not meet the current workload review thresholds, CMSCenters for Medicare and Medicaid Services will not issue responses indicating that the review criteria have not been met.” In the past, CMSCenters for Medicare and Medicaid Services has verbally stated that they will no longer issue “Does Not Meet Threshold” (DNMT) letters; however, in PMSI’s experience CMSCenters for Medicare and Medicaid Services has continued to issue these letters nonetheless. Regardless, CMSCenters for Medicare and Medicaid Services does still maintain the following: “These thresholds are created based on CMSCenters for Medicare and Medicaid Services’ workload, and are not intended to indicate that claimants may settle below the threshold with impunity. Claimants must still consider Medicare’s interests in all WC cases and ensure that Medicare pays secondary to WC in such cases” (see section 8.1).
Independent Medical Evaluations (IMEs): The guide also provides further insight as to CMSCenters for Medicare and Medicaid Services’ view of IMEIndependent Medical Examiner records. The guide states that an IMEIndependent Medical Examiner opinion may be sufficient under certain circumstances, e.g., the claimant has not received treatment in several years and there is no primary care physician (see section 10.1.7). However, under the Do Not Submit section the guide states that IMEIndependent Medical Examiner evaluations are not treatment records, but they may be appropriate to determine future treatment requirements under certain circumstances; however they are not appropriate as medical records. This information regarding IMEIndependent Medical Examiner opinions is not new either; however, it does provide further clarification regarding CMSCenters for Medicare and Medicaid Services’ view/deference to IMEIndependent Medical Examiner opinions when reviewing proposed WCMSAWorkers' Compensation Medicare Set-Aside allocations.
In summary, the WCMSAWorkers' Compensation Medicare Set-Aside Reference Guide is a great reference tool which combines previously issued guidance from CMSCenters for Medicare and Medicaid Services into one document; however, the guide does not seem to provide any new insight into the current WCMSAWorkers' Compensation Medicare Set-Aside process. PMSI is hopeful that CMSCenters for Medicare and Medicaid Services will continue to revise the WCMSAWorkers' Compensation Medicare Set-Aside Reference Guide as updates from CMSCenters for Medicare and Medicaid Services arise. Within these future updates, PMSI hopes to see a more comprehensive set of WCRCWorkers’ Compensation Review Contractor Operating Rules as well as adding an appeals process to WCMSAWorkers' Compensation Medicare Set-Aside submissions to create greater visibility and fairness into the WCMSAWorkers' Compensation Medicare Set-Aside approval process.
Comments (0) 
As of January 1, 2013, Medicare expanded its Part D guidelines to include coverage for benzodiazepines and barbiturates for certain conditions. For more information on this new expanded coverage, when it will be covered, and how this coverage change is predicted to apply to WCMSAs, please see our prior blog here.
Themocracy