Sacramento, CA - The WCRC, the entity which reviews Workers' Compensation Medicare Set-Asides (WCMSAs) for the Centers for Medicare & Medicaid Services (CMS) has issued the award to Capitol Bridge LLC, a government services firm with its headquarters in Arlington, Virginia. The award notice is as of September 1, 2017.
The purpose of the Workers' Compensation Review Contractor contract is to independently price the future Medicare-covered medical services costs related to WC injury, illness, and disease, and to price the future Medicare covered prescription drug expenses
Over the past several years, requirements for Workers' Compensation Medicare Set-Asides (WCMSAs) have been somewhat well-established. The Centers for Medicare and Medicaid Services (CMS) now routinely update their WCMSA Reference Guide, providing detailed information on how to handle payment for Medicare-eligible expenses on behalf of beneficiaries who have received settlements in workers' compensation cases.
For liability cases, however, CMS has been far less clear, making it difficult for claimants and their attorneys to ensure that Medicare won't seek reimbursement down the road. However, it appears as though some major changes are imminent.
CMS recently issued a notification directing Medicare Administrative and Recovery Contractors (MACs) to create a set-aside process for Liability Medicare Set-Asides (LMSAs), as well as for No-Fault Medicare Set-Asides (NFMSA). The new process is scheduled to go into effect as of October 1, 2017.
The Medicare Secondary Payer (MSP) provision outlined in 42 U.S.C. §1395y(b)(2) and §1862(b)(2)(A)(ii) of the Social Security Act do specifically reference "an automobile or liability insurance policy or plan (including a self-insured plan) or no-fault insurance," under the umbrella of primary payers for claims related to settlements, judgments, awards, or other payments. The direction given to the MACs should now provide some framework for claimants involved in non-workers' compensation cases.
Noteworthy of the award is that it is for approximately $60 million dollars, which is safe to say that CMS expects the WCRC to engage in a large number of MSA reviews. According to the Request for Proposal (RFP) for this award the WCRC will also potentially begin reviewing Liability Medicare Set-Asides (LMSAs) and No-Fault Medicare Set-Asides (NFMSAs) as early as July 1, 2018 which is likely the reason for the large award amount, in addition to an increased volume of WCMSAs over the years.
Since 2011, Provider Resources, Inc. has been the contractor reviewing WCMSAs. There have seen good turnaround times from Provider Resources and it is likely that Capitol Bridge LLC will continue to provide MSA approvals expeditiously.
It will be interesting to keep an eye on how Capitol Bridge reviews MSAs and also adopts updated guidance in the new WCMSA Reference Guide. Since the issuance of the Reference Guide, the industry has seen a shift in some of the WCRC's approval policies.
The current WCRC is now requiring a court order to approve a zero allocation based upon denial of the claim. Further, with California MSAs in which the employer/carrier has relied upon a binding Utilization Review (UR), WCRC is now requiring an Independent Medical Review (IMR) decision or a court order to support the UR.