Tag Archives: Workers’ Compensation Review Contractor

Trends affecting Workers’ Compensation Medicare Set-Aside Allocations

Capitol Bridge, LLC, the newest Workers’ Compensation Review Contractor (WCRC) for the Centers for Medicare and Medicaid Services (CMS), officially took over on March 19, 2018. Since that time, the Medicare Set-Aside (MSA) industry has noticed aggressive changes in the Workers’ Compensation Medicare Set-Aside (WCMSA) review process, resulting in an increase in WCMSA allocations.

At Optum, it is our practice to monitor CMS determinations to identify changes in the WCMSA voluntary review process and provide an update to our clients. This effort helps avoid counter-high discrepancies that occur when the WCRC makes a change to the methodology used to review WCMSAs.

The following is a summary of changes affecting WCMSA’s.

Urine Drug Screens increase in frequency

Starting in July of 2018, the WCRC changed its protocol for urine drug screening (UDS) when an opiate medication is included. Up to this point, it was standard practice to allow for one UDS annually, unless the treating physician is ordering them more frequently based on risk assessment.  The WCRC is now allocating a minimum of four UDSs annually when opiate (Schedule II narcotic) medications are prescribed (Tramadol is not a Schedule II narcotic).

Optum received the following statement from the CMS regarding this change:

“When changes were made to prescribing requirements related to hydrocodone products back in 2015, UDS requirements were set to match prescribing needs. Now that prescribers may only write single monthly prescriptions without refills and up to no more than three prescriptions between visits, UDS expectations were set to each of those visits unless the prescriber was ordering them more frequently.” 

According to The Official Disability Guidelines (ODG), the frequency of urine drug testing should be based on documented evidence of risk stratification, including use of a testing instrument. Allocating for four UDSs per year for all claimants using Schedule II opioid analgesics does not appear to be consistent with the current clinical guidelines, which promote performing an individual risk assessment for each patient. Due to the heightened awareness of the risks associated with opiate analgesics, it is felt that the WCRC is taking a more conservative approach in order to assure proper safety. However, each case is different and guidelines support the treating physician making an assessment that is specific to each patient.

The increased frequency in drug testing is causing an increase in WCMSAs. Additionally, the pricing for the UDS tests have also increased in every state. CMS explained their rationale for the increases on several cases as follows:

  • “The claimant was prescribed opiate medications. Therefore, frequency of urine drug screens was increased from once per year to four times per year” (Resulted in an $8,824.00 counter high).
  • “The frequency of the urine drug screen testing is higher than the proposed frequency and the medical pricing of this test is higher than the proposed pricing” (Resulted in an $8,609.00 counter high).
  • “Additional medical services are indicated including increased frequency of urine drug screens for monitoring of opioid medications” (Resulted in a $7,896.00 counter high).
  • “Additional medical services are indicated, increased frequency of urine drug screens based on the opiate prescribed” (Resulted in a $14,562.00 counter high).

Lyrica® now routinely included in WCMSAs

Please click here to read our in-depth blog regarding the WCRC including Lyrica in WCMSAs.

Liberal interpretations of surgical recommendations

Recently, the WCRC included a future surgery where the physician stated, “With regard to the potential need for future treatment if he (the claimant) does develop arthritis of the subtalar joint and has persistent pain which cannot be controlled through other methods he may require a subtalar joint arthrodesis.”

This statement is not a conclusive recommendation for future surgery. First, surgery is needed only if the claimant develops arthritis and, secondarily, if the associated pain is not controllable through other measures. This statement was certainly not indicative of a firm recommendation from the physician that this treatment would be medically necessary in the future. Several things need to occur in order for surgery to be needed in the opinion of the physician.

The Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide Version 2.8 indicates:

“If the item is recommended in the medical record and is covered by Medicare, it will be included in the WCMSA, regardless of whether it follows medical association guidelines. The WCRC makes every effort not to include services that are not recommended in the medical records unless the service is always part of the treatment. The WCRC reviews proposals on a case-by-case basis. They consider the treatment and usage patterns, the recommendation of the treating providers, life expectancy, functional status, responses to treatment and effectiveness of therapies as established in the records. The WCRC references evidence-based guidelines as resources in determining future treatment.”

The CMS determination letter indicated:

“On 3/28/2018, it is noted that claimant might require the use of an orthotic and if claimant developed arthritis of the subtalar joint with persistent pain that could not be controlled through other methods, a subtalar joint arthrodesis might be needed. Future treatment will include: physician visits, diagnostic studies, physical therapy, ankle surgery and orthotic/cane.”

Optum resubmitted this case requesting all treatment added by the WCRC in relation to the ankle surgery be removed. The WCRC declined the request and stated that the “after review of the existing records, on 10/25/2017, x-rays completed revealed reduced joint space with some broadening of the calcaneus. This is indicative of subtalar joint arthritis.” 

There was no indication in the medical records that there was a diagnosis of arthritis. The statement from the treating physician alone confirmed this, since the physician indicated that the surgery is needed only “if” the claimant develops arthritis. Additionally, it is difficult to predict whether the claimant would have pain not controllable by other more conservative methods. We do not agree with this determination by the WCRC and feel that there is no current evidence to support its inclusion.

Increased turnaround times

The previous WCRC had a turnaround time of approximately nine days. The current WCRC is averaging 25 days for review of a WCMSA. We are hopeful that over time, the turnaround times will decrease and be more in line with the previous contractor.

As always, we will continue to update the property and casualty insurance industry with news, trends or additional updates from CMS and the WCRC.

WCMSAP Now Allowing Users to Directly Input Prescription Drug Information

As of yesterday, October 6, 2014, users of the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) can now directly input prescription drug information and calculate the proposed prescription drug portion of a WCMSA proposal. Please see our prior blogs for more information on this release: our blog discussing the initial alert issued by CMS announcing this functionality can be found here, and our secondary blog which links to and discusses a subsequent presentation issued by CMS explaining this functionality can be found here.

Our initial impressions of this functionality show that users must input case information on a claimant/case prior to be able to look up the prescription drug pricing. In other words, users cannot just look up a drug without providing corresponding case information first. This new functionality is going to be extremely helpful and eliminate discrepancies from AWP differences.  We are very pleased that this functionality is now available.

CMS Clears WCMSA Backlog

Yesterday afternoon, PMSI received several hundred WCMSA determinations which were noted to have been reviewed as part of a streamlined review process. The vast majority of these determinations appear to be “rubber-stamped” (approved as submitted) and related to files in which CMS had previously issued a development letter requesting additional information.

No official statement regarding this streamlined review process has been transmitted by CMS at this time. However, PMSI believes that increased pressure upon CMS and the WCRC to clear its backlog and cease seeking medical records that are either unavailable or unrelated to the injury prompted CMS to clear many WCMSA proposals.

PMSI applauds this action by CMS and the WCRC, and is grateful that continued advocacy with CMS has resulted in a positive outcome for all. While we are not certain if CMS will change any of its policies and procedures as it relates to review of WCMSAs as outlined in the reference guide, we are pleased to see that CMS is responding to issues raised by stakeholders.

We will continue to monitor the streamlined review process for any changes whether temporary or permanent and keep our subscribers updated.

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.