Streamlining the Workers’ Compensation Medicare Set-Aside Process

My last column explored the development and implementation of the CMS Medicare Secondary Payer Recovery Portal (MSPRP) by the Centers for Medicare and Medicaid Services (CMS). Like the MSPRP and settlement of conditional payments, the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) has helped streamline the submission and review process for Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) cases. Other positive trends affecting the WCMSA practice include the move by the Workers’ Compensation Review Contractor (WCRC)—Provider Resources Inc.—over the past year toward a faster, more evidence-based MSA review protocol and the recent WCMSAP upgrade involving MSA reconsideration requests.

CMS developed and implemented the WCMSAP in 2011. According to its website, the portal is the recommended method for submitting a WCMSA and allows for electronic submission. Attorneys, Medicare beneficiaries, claimants, insurance carriers, and workers’ compensation MSA vendors may use the portal to enter WCMSA information directly. There is, however, a required registration process that prospective users must complete before gaining access to the portal.

Presubmission Process

Prior to the establishment of the WCMSAP, WCMSAs were submitted to CMS for review through the mail. The submitter would create a disk of documents and mail it to the Coordination of Benefits Contractor (COBC), which would then upload the documents and send them to the WCRC for review. Following its review, the WCRC would issue and mail its decision as to whether or not it approved the WCMSA. If the WCRC needed additional information to complete its review, it would issue a “development letter” requesting additional information. If the WCRC issued a development letter and did not receive a response for the requested information, it would issue a “closing letter,” which effectively suspended the review of the WCMSA until the submitter provided the requested information.

Users identified several problems with the old submission system, including documents getting lost going to and from CMS and the extra time added to the process by the use of a middleman to transmit the WCMSA documents to the WCRC.

WCMSAP Submission Process

The WCMSAP is a secure, Web-based application. Registered users can bypass the COBC and submit WCMSAs directly to the WCRC by entering case information and uploading documentation. Further, users receive case status information directly from the WCRC through online notifications and emails.

CMS.gov identifies several features and benefits of using the portal. Users can create a work-in-progress (WIP) case by entering and saving partial information while continuing to gather necessary information to complete the WCMSA. Users receive from CMS immediate confirmation of the receipt of the WCMSA submission and notification of issues or errors found within the submitted documentation. The WCMSAP also allows users to correct any errors CMS identifies by adding documentation to the submission. Users can search for and view a previously submitted WCMSA or a WIP order to obtain case status information, view alerts related to the case, or append documentation to the case.

Submitting a WCMSA for approval through the WCMSAP also results in a much shorter turnaround time for receipt of the WCRC decision. Users may expect to receive a decision within 30 to 60 days following submission through the portal. That’s in contrast with the 270 or more days that submitters could expect to wait for a decision in some cases prior to the WCMSAP.

WCMSAP Upgrade

Earlier this year, CMS upgraded the WCMSAP to enhance its ability to accept re-review requests related to WCMSA submissions. When a WCMSA is submitted to CMS for approval, CMS may approve the amount of money allocated to fund the WCMSA, or it may decide a higher amount should be used to fund the account. When CMS recommends a higher amount, such a decision is called a CMS “counter higher.” A submitter may make a further request—called a re-review or a rebuttal—for CMS to reconsider its decision.

While the WCMSAP has always had the functionality to accept re-review requests, the upgrade allows the submitter to designate a submission as a re-review request simply by clicking a button. That improves on the prior method of transmitting a re-review request, which was the same process as the submission of final settlement documents to the regional office of CMS reviewing the case. If the regional office missed the designation of the submission as a re-review, a delay would ensue before the reconsideration process. That delay was detrimental to parties waiting to see whether CMS would reduce the MSA amount prior to entering into a final settlement. Now, the new functionality obviates the risk of a delay.

Soon after CMS upgraded the portal, it released a Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide (March 29, 2013, V1.3). This reference guide is an excellent compilation of informational materials—including previous CMS memos, current WCMSA submission thresholds, WCMSA funding options, and the WCMSA submission process, among other topics. While the reference guide doesn’t change CMS guidelines or procedures, it does, however, include a section on re-review requests (Section 16.0).

A submitter may request a re-review if: the submitter provides the regional office with additional information to justify the submitted WCMSA amount; the CMS determination contains “obvious mistakes,” such as a mathematical error or a CMS failure to recognize previously submitted medical records; or there is new evidence that is dated prior to the submission date of the original proposal.

As always, please feel free to email me at jsmythe@cpscmsa.com with your comments and questions. Thank you for all the great feedback from my last column. I look forward to seeing you this fall at the next CLM event.