On November 7th, we notified our subscribers that CMS had issued a new WCMSA Reference Guide (dated 11/1/2013). To access our prior blog which contains a high-level overview of the new Reference Guide, please click here.
Since our last blog posting, PMSI has conducted a thorough review of the WCMSA Reference Guide and would like to highlight some of the more noteworthy updates. The Reference Guide can also be found on the CMS website here.
- In Section 8 of the Reference Guide, CMS clarified that “If the parties to a WC settlement stipulate a WCMSA but do not receive CMS approval, then CMS is not bound by the set-aside amount stipulated by the parties, and it may refuse to pay for future medical expenses in the case, even if they would ordinarily have been covered by Medicare. “
PMSI Comments: While this information is not necessarily new, it is interesting that CMS has now explicitly stated this point. CMS does go on to state within this section and acknowledge that there are no statutory or regulatory provisions requiring the submission of a WCMSA proposal to CMS for review.
- In Section 9.4.4 of the Reference Guide, Step 5,CMS states that if a state institutes or changes a fee schedule, the WCRC will apply the new fee schedule immediately upon learning of its official publication, regardless of official effective date, for any case still in process on that date.
PMSI Comments: While PMSI supports CMS staying up to date on a state’s most current fee schedules, to adopt a new fee schedule to an MSA that is already in process for review at CMS may make the submission process unpredictable for submitters. Additionally, submitters are not aware of how often CMS checks for updates and how soon it will be able to adopt the new fee schedules, etc.
- In Section 9.4.5 of the Reference Guide, CMS clarified frequency and/or pricing for various medical items such as MRIs, CT scans, surgical procedures and trials.
PMSI Comments: Submitters appreciate this guidance from CMS which will be helpful in understanding how CMS allocates for these items.
- In Section 184.108.40.206 of the Reference Guide, CMS clarified that the WCRC continues to price Part D drug products based on AWP and further based on brand or generic drug pricing. AWP pricing is pulled from a proprietary source, Truven Health Analytics’ Red Book database. The WCRC uses a program for drug pricing that uses Red Book flat files updated quarterly, and soon to be updated monthly. For generic drugs, the WCRC uses the lowest non-repackaged generic drug AWP.
PMSI Comments: The industry collectively has been seeking to pinpoint how often CMS was updating its Red Book pricing. While many submitters receive updates from Red Book daily, it was never published how often CMS was updating their pricing. PMSI appreciates this update from CMS and hopes that CMS will continue to keep the industry apprised of any changes to how often it updates its Redbook pricing, but remains concerned that submitted MSAs may experience a price
change during the process and erode some predictability. PMSI encourages CMS to adopt a practice that uses pricing based on the date submitted.
- In Section 220.127.116.11 of the Reference Guide, it states 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.
PMSI Comments: While this clarification is helpful and confirms that weaning will be taken into consideration by CMS if already underway, it does not allow for an accurate WCMSA when the physician plans to continue the weaning process.
If you have any questions on the new Reference Guide, or if PMSI can be of further assistance, please contact us at firstname.lastname@example.org.
CMS has released an updated User Guide for NGHPs. Although the User Guide is dated October 7, 2013, it was not released to the public until October 18, 2013. Access to the updated User Guide can be found here.
User Guide 4.0 incorporates changes announced via alerts over the past several months in relation to the conversion to ICD-10 coding with respect to MMSEA Section 111 Mandatory Insurer Reporting.
PMSI encourages RREs and claim administrators to review the new User Guide in its entirety to ensure compliance. However, we have noted the following as a summary of the more significant updates included in the new User Guide:
- Inclusion of three June 2013 alerts regarding transition to ICD-10, testing for
ICD-10 codes, and new ICD-9/10 excluded codes.
- Layout changes to the claim input file detail record include repurposing of the ICD-9 fields to accommodate ICD-10 code lengths by adding spaces that were reserved for future use in previous editions of the Guide. A new ICD indicator has also been added from reserved space and will be used to indicate which coding has been utilized within the claim.
- Inclusion of updated hyperlinks on Medicare and COBC web pages where outdated hyperlinks existed.
- Disposition code 50 has been clarified; CMS indicates that RREs should only expect to receive a low volume of responses with this code.
- Computer Based Training (CBT) Modules: Users no longer need to register for CBTs and the modules can be accessed directly from the CMS website.
In addition to the updated User Guide, CMS issued a revision to the August 14, 2013 alert regarding diagnosis codes that are no longer valid for reporting as of January 6, 2014. This revision adds ICD-10 cluster codes related to diabetes to the list of invalid codes. A copy of the revised alert can be obtained here (CMS has indicated changes with a bold font for ease of reference).
On September 30th, we issued a blog about the government shutdown and predictions as to how it would affect the various operations at CMS and other entities charged with MSP operations. Please click here to read our prior blog.
As our subscribers are probably aware, it has now been over a week since the government shutdown commenced and it is unclear as to when it will cease. PMSI would like to provide the following update to its subscribers:
CMS Approval Letters and the WCRC:
Over the past week, PMSI has still been receiving MSA approval letters from CMS, although fewer than usual. PMSI has learned from its contacts at the WCRC that the CMS Regional Offices are operating with a “skeleton crew,” and therefore some CMS approval letters are still being issued. However, approval letters are not being issued at normal volume and therefore the industry can expect fewer approval letters than usual until the shutdown ceases.
If a call is placed to any of the CMS Regional Offices, your call will be responded to with the following message: “Due to the absence of either a fiscal year 2014 appropriation, or a continuing resolution for the Department of Health and Human Services, our offices are in furlough and we are not able to respond to your message.”
Conditional Payment Processes and the MSPRC:
Over the past week, the MSPRC appears to be operating normally as predicted and the conditional payment process appears to not be affected.
As usual, PMSI will continue to keep our subscribers updated on the government shutdown and any affect it may have on the MSP processes.
As of 2:30 P.M. EST this afternoon, the U.S. Senate has rejected the latest House “Continuing Resolution” needed to fund federal government operations beyond the end of the fiscal year, set to end tonight, September 30th at midnight. Therefore, it appears very likely that the Government will shut down, at least for several days, starting tomorrow, October 1st.
Most relevant to CMS and MSP operations, PMSI has learned through the MARC Coalition that although the shutdown will result in many CMS staff being furloughed, it will NOT result in termination of operations at the MSPRC.
More specifically, CMS has indicated that all Coordination of Benefits/MSP contractors will be operating under normal hours, and that CMS does not expect any announcement to be posted. It is presumed that the MSPRC and COBC are operating using FY13 funding. Thus, while the CMS staff may not be at work tomorrow, the contractors will continue normal operations.
PMSI will continue to follow the shutdown and will keep suscribers notified of any significant changes relevant to CMS and the MSP.