Tag Archives: WCRC

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.

CMS Seeking to Expand its WCMSA Re-Review Process

On February 11, 2014, CMS issued an alert regarding a proposed expansion of the WCMSA re-review process. The alert states the following:

The Centers for Medicare and Medicaid Services (CMS) announced on February 11th that it is seeking comments on the manner in which CMS plans to expand the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) re-review process. See: http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/Downloads/WCMSA-Re-review-Expansion.pdf. Currently, CMS has a limited re-review process for WCMSA amounts that can be used in situations where CMS is notified that the submitter omitted documentation from the original proposal or when a mathematical error was made by Medicare’s review contractor.

Below is a summary of the proposed expanded re-review process. CMS is asking for comments on all aspects of the proposal, including comments on the timeframe, threshold and reasons for granting a re-review. Once the process is finalized, CMS will post implementation dates and detailed instructions on how to use this process on the WCMSA website. Comments or concerns with the proposed process should be sent to WCMSARereview@cms.hhs.gov  by March 31, 2014.

Under the planned expanded process, re-reviews will be available for a broader array of categories and reasons. All requests for re-review will be sent to the Workers’ Compensation Review Contractor (WCRC) for resolution within 30 business days. The WCRC will direct the request to a group of experts best skilled to review the identified issue. The experts that perform the re-review will not be the same specialists involved in the original determination.

I. Re-review requests can be submitted at any time to the WCRC for
the following reasons:

  • A mathematical error was identified in the approved set-aside amount.
  • Original submission included case records for another beneficiary.

II. Re-review requests can be submitted to the WCRC when the original WCMSA was approved within the last 180 days; the case has not settled; no prior re-review request has been submitted for this WCMSA; and, the re-review requests a change to the approved amount of 10% or $10,000 (whichever is more) for any of the following reasons:

  • Submitter disagrees with how the medical records were interpreted.
  • Medical records dated prior to the submission date were mistakenly omitted.
  • Items or services priced in the approved set-aside amount are no longer needed or there is a change in the beneficiary’s treatment plan.
  • A recommended drug should not be used because it may be harmful to the beneficiary.
  • Dispute of items priced for an unrelated body part.
  • Dispute of the rated age used to calculate life expectancy.

In certain situations, a re-review may be elevated by the WCRC to a CMS Regional Office. This level of review will occur in situations such as, failure to adhere to court findings; CMS policy disputes; carrier maintains Ongoing Responsibility for Medicals for treatment that has been included in approved WCMSA, etc.

CMS will schedule a Town Hall Teleconference prior to implementation of the expanded re-review process.

PMSI is pleased that ongoing discussions and meetings with CMS/HHS over the past two years with industry stakeholders such as PMSI, has resulted in these positive proposed changes to the WCMSA process. Additionally, PMSI applauds CMS for seeking not only to expand  the WCMSA re-review process, but for also including in the proposed changes to address specific concerns raised by stakeholders.

PMSI will be filing comments in response to this notice from CMS. We encourage our subscribers to also submit comments as this will greatly impact the process in which stakeholders are able to voice concerns on previously submitted and reviewed WCMSAs.

New WCRC Vendor Taking Over 7/2/12

It appears that the new WCRC vendor, Provider Resources, Inc., will be taking over the review of all WCMSA submissions beginning July 2, 2012. A message was recently posted to the WCMSAP confirming the following:

Effective July 2, 2012, please contact the WCRC, regarding Workers Compensation Medicare Set-aside (WCMSA) proposals submitted to CMS for review, at the following toll free: 1-(855) 280-3550. All mailing addresses will remain the same.

The transition over to Provider Resources, Inc. has been underway for some time now and was delayed due to a protest that was filed and ultimately dismissed.  PMSI is hopeful that the transition to the new contractor will improve the overall WCMSA review and approval process as well as related turnaround times.

WCRC Contract Protest Dismissed

On August 3, 2011 the GAO dismissed the protest filed by Data and Analytics Solutions, Inc. in reference to the WCRC contract awarded to Provider Resources, Inc. effective July 1, 2011. Data and Analytics Solutions, Inc. had filed a bid for the WCRC contract and was not chosen. They filed the protest alleging that the agency’s review process was flawed. The GAO was given a deadline of October 13, 2011 to render a decision in reference to the protest. The MSA industry is pleasantly surprised by such a quick decision by the GAO; the swift decision is welcome news so that the transition to the new WCRC provider can take place.

The transition of the WCMSA review process from Lifecare Management Partners to Provider Resources, Inc. will soon commence. The industry is waiting to see whether the transition to a new contractor will improve the overall review and approval process and related turnaround times.  

Click here to view a copy of the GAO Bid Protest Docket.

Click here to view the MedicareInsights.com July 14, 1011  post about the protest and delay.