PMSI - Settlement Solutions PMSI - Settlement Solutions

Posts tagged: workers’ compensation

Highlights from Recent CMS NGHP MIR Teleconference

By , April 10, 2013 2:50 pm

CMS held a teleconference regarding MMSEA Section 111 Reporting on April 9, 2013 which pertained to Liability Insurance (including Self-Insurance), No-Fault, and Workers’ Compensation collectively recognized as Non-Group Health Plans (NGHP). During this teleconference, CMS addressed various topics, including, but not limited to MMSEA Section 111 Reporting, recent MIR alerts, and the implementation of ICD-10 as it relates to reporting.

Please note that this blog only touches on some of the highlights of the CMS Teleconference1 and is not all-inclusive of items discussed during the teleconference. CMS stated that all official guidelines are posted on the Section 111 web page at If there are any conflicts between the documents/information posted on the web site and what is stated on the teleconference, the written documents/information posted on the web site prevail.

A schedule of upcoming teleconferences will be available on the website; there are no future scheduled teleconferences at this time.

CMS posted an alert on March 24th regarding data elements that are now optional rather than required. CMS hopes that it will simplify the process for RREs. The alert is available on the website.

The profile recertification process for RREs has been put on hold temporarily but is scheduled to resume in the near future. Recertification will not occur as it did in 2012 with many RREs going through recertification at the same time. The activity in 2013 will be evenly distributed throughout the year and an RRE that recertified in early 2012 may find their 2013 recertification to be later in the calendar year. In 2014, the RRE should receive the recertification request on the anniversary of the recertification from 2013. RRE should wait to receive the recertification request before contacting the COBC.

For technical support, RREs should always utilize the escalation process provided in the NGHP User Guide.

An updated NGHP User Guide is expected to be issued in May 2013. However, most updates will include alerts previously issued and information previously provided by CMS. The updates to the User Guide will be notated in the first chapter of each section of the User Guide.

Questions submitted to the Section 111 mailbox

Will CMS add an ICD-9 code for Instantaneous Death?

CMS has no current plans to make this an acceptable ICD-9 code. RRE’s will need to follow up and find information about the injuries which lead to the death.

What should an RRE do if a query was submitted for a 65 year old individual but the query did not find the individual to be a Medicare beneficiary?

If the individual did not match in CMS’ system, the individual is likely not a Medicare beneficiary. However, the RRE should double check the information being submitted and be sure that the information submitted is accurate. There should be no need for further action by the RRE; however, CMS recommends that the RRE do one query on or after the date of settlement due to the fact that the beneficiary may be pending receipt of benefits when initially queried. The RRE can cease querying after they confirmed they are not a beneficiary at the time of settlement.

If an individual is no longer treating, but the RRE retains legal responsibility due to the fact that the state does not allow the closure of future medical treatment, how should these claims be reported?

Even if the individual is not currently receiving treatment, it should be treated as an open ORM in the event that the beneficiary may require further treatment. The RRE should not terminate ORM until legal responsibility for future medical treatment is terminated. The fact that an RRE has administratively closed a case does not mean ORM should be terminated.

If a liability settlement occurs that is exactly $5,000, is that currently reportable?

The current liability TPOC thresholds run from October 1, 2012-September 30, 2013 and only settlements over $5,000 need to be reported. Therefore, if the TPOC occurred after October 1, 2012 and it was for exactly $5,000 it would not be a reportable claim. However, the RRE may voluntarily report the claim.

When will ICD-10 be applied to Section 111, and if so, how does CMS plan to implement ICD-10?

As of right now, October 1, 2014 is the roll out/go-live date for ICD-10. CMS plans to start testing in October 2013 to give the industry a year to get ready for ICD-10 implementation for Section 111. CMS will issue an alert confirming the requirement of ICD-9 versus 10 when they have made a firm decision.

Will CMS answer questions regarding the SMART Act on today’s teleconference call?

No questions regarding the SMART Act will be answered. The SMART Act will be implemented per CMS timelines and through rulemakings.

Open Question and Answer Session  

Regarding loss of consortium and other derivative claims, if a spouse files and releases “all claims” in a settlement, but the spouse did not make any emotional/physical claim should the “NOINJ” code should be used? Is the claim reportable even if medicals are not part of a wrongful death settlement?

Yes, the “NOINJ” code should be used in this situation, and there is a separate report for each individual-i.e., both spouses should have separate reports. Yes, the claim is still reportable even if medicals are not part of the wrongful death settlement; RREs are not permitted to interpret state laws for CMS.

In a no-fault claim, if the Statute of Limitations (SOL) has ran, can the RRE terminate the ORM?

Yes, if the no-fault carrier is going to cease payment and will not pay anything after the SOL has expired then the RRE can terminate the ORM.

In a liability case where a Medicare beneficiary will require future treatment, but the Plaintiff agrees in writing to pay for their future medical care, will the defendant be subject to future liability by Medicare?

CMS refused to answer this question and stated that it was “outside the scope of the call.”

With respect to the ANPRM issued last year regarding MSP and future medicals, is there any sense of timing as to when the industry will receive proposed rules or the agency’s next steps or statements? How will the ANPRM affect defendants?

CMS also refused to answer this question. They noted that the industry can look for updated announcements in the Federal Register. They also noted that even the people working on CMS rulemakings often times do not know the day it will be published.

What should RREs do when Medicare beneficiaries are being denied coverage or treatment for items not related to their liability or workers’ compensation case?

CMS recommends that RREs provide the recent MedLearn article that CMS issued which makes it clear that an open liability, no-fault or workers’ compensation case is not a basis for a provider denying treatment.

In terms of payment, CMS does have prompt pay rules, unless there is ORM posted related to the claim. Most cases are denied appropriately; however, the beneficiary can also appeal the denial. The beneficiary can also call 1-800-Medicare or can seek assistance from their local regional office.

If there is a liability policy that also has MedPay, and payments are made incrementally under MedPay, would that be reported as ORM?

This would be reported as ORM; MedPay is ORM since it is a type of no-fault.

With regard to the March 24th alert, if there are errors that come back from a prior submission and the error is contained within a field that is now “optional” pursuant to the March 24th alert, should the RRE disregard the error report or make the correction?

On the next quarterly submission, you can remove your e-code only if it was blank in the first place. However, if information was provided that was incorrect, it should be corrected on the next quarterly submission.

What if a claim was made with ICD-9 codes but becomes reportable after October 2014? How will that be reported to CMS?

CMS’ intent is to allow the ICD-9s to continue to be reported; however, this is something that CMS is looking into. CMS does not expect people to interpret/transfer ICD-9 to ICD-10. The goal is to make this as easy as possible for everyone.

1. Questions and answers have been paraphrased.
This blog is provided as reference material and is based on verbal information derived from third parties during teleconferences hosted by the Centers for Medicare and Medicaid Services (CMS). PMSI does not assume liability or responsibility for the accuracy or completeness of the material in this document. The information contained herein should not be construed as an endorsement of any kind or an official transcript of the teleconference. PMSI makes no representation or warranties of any kind, either express or implied, that this information is accurate, up-to-date, or error free and PMSI shall not be liable in any amount for any damage, however arising, that may occur as a result of your reliance on this information. This document is advisory in nature only and does not represent official policy, procedures, or opinions of CMS or PMSI. For official information regarding Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA), refer to the official web page


Reminder: PMSI to Host CE Accredited Webinar

By , April 8, 2013 2:53 pm

Next week, Heather Schwartz, Esq., MSCC, CHPE, CLMP, CMSP will offer her expertise in reference to the SMART Act and other MSP legal updates on Tuesday, April 16, 2013 from 1 PM -2 PM EDT.

The webinar is complimentary and 1 hour of CEU and CLE credit has been applied for in multiple states; all attendees who successfully complete the Webinar will be provided with a Certificate of Attendance. For more information on obtaining CEU or CLE credit for this webinar and to Register, please click here.


CMS to Host a WCMSA Teleconference

By , April 2, 2013 4:21 pm

CMS has announced that they will be hosting a WCMSA Teleconference on April 11, 2013 from 2:30-4:30 PM EST. The notice states the following:

What’s New

April 1, 2013

Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Town Hall Event

The CMS will be hosting a WCMSA teleconference on April 11, 2013. This event will provide stakeholders an opportunity to learn more about the Workers’ Compensation Review Contractor (WCRC), and discuss procedural matters that are not case specific.

In an effort to address as many topics as possible, CMS is requesting stakeholders to submit non-case specific questions they would like to have addressed during the teleconference to the CMS MSP Central mailbox* prior to the teleconference. CMS will review and categorize the questions submitted and attempt to answer as many questions as possible during the teleconference. There may also be an opportunity for the stakeholders to ask questions after the presentation.

Date of Teleconference:   April 11, 2013

Call-in time for all calls:    2:30-4:30p.m. EST

Call-in line:                      (800) 603-1774

Pass Code:                      WCRC

Questions for call:            Please submit to CMS*

Questions may be submitted beginning April 1, 2013 thru April 5, 2013 @ 3:30 p.m. EST.

All questions submitted for the teleconference to the email address shown above should clearly state in the subject line “WCRC April 11, 2013 Town Hall Teleconference.”  

Note: Questions submitted to the mailbox after the date and time noted above will not be considered.

PMSI encourages it subscribers to submit questions directly to CMS at the e-mail address listed above. We applaud CMS for holding this teleconference and are looking forward to receiving clarity from CMS on common industry questions and issues in WCMSAs.


CMS Issues WCMSA Reference Guide

By , April 1, 2013 3:49 pm

On March 29, 2013, CMS issued its first ever WCMSA Reference Guide. To view and download a copy of the guide, please click here.

At the beginning of this 88 page guide, CMS states that the guide was written to “. . . help you understand CMS’ Workers’ Compensation Medicare Set-Aside Arrangement amount approval process and to serve as a reference for those electing to submit such proposals to CMS for approval.”

The guide appears to reflect information compiled from previously issued WCMSA Regional Office Memorandums issued by CMS, and information provided on the CMS WCMSA 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 WCMSA Reference guide:

WCMSA Portal: CMS has included information relevant to the online WCMSAP online portal. This portal is not new and has existed since November of 2011; however, it appears to be the first time in which CMS has issued formal guidance around the portal since it was initially introduced (see section 9.1 for more information on the WCMSA portal).

List of WCRC Review Reference Tools: CMS has provided a list of review reference tools used by the WCRC (the WCRC is instructed to utilize these tools when reviewing a proposed WCMSA). 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 WCRC contractor. Therefore, an updated set of Operating Rules would provide insight as to how the new WCRC 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 CMS Review Threshold: The guide states that “. . . if an individual’s WC settlement does not meet the current workload review thresholds, CMS will not issue responses indicating that the review criteria have not been met.” In the past, CMS has verbally stated that they will no longer issue “Does Not Meet Threshold” (DNMT) letters; however, in PMSI’s experience CMS has continued to issue these letters nonetheless. Regardless, CMS does still maintain the following: “These thresholds are created based on CMS’ 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 CMS’ view of IME records. The guide states that an IME 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 IME 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 IME opinions is not new either; however, it does provide further clarification regarding CMS’ view/deference to IME opinions when reviewing proposed WCMSA allocations.

In summary, the WCMSA Reference Guide is a great reference tool which combines previously issued guidance from CMS into one document; however, the guide does not seem to provide any new insight into the current WCMSA process. PMSI is hopeful that CMS will continue to revise the WCMSA Reference Guide as updates from CMS arise. Within these future updates, PMSI hopes to see a more comprehensive set of WCRC Operating Rules as well as adding an appeals process to WCMSA submissions to create greater visibility and fairness into the WCMSA approval process.


Panorama Theme by Themocracy