The Centers for Medicare and Medicaid Services (CMS), like most government administrative agencies, generally moves at its own pace. After alluding to an updated re-review process in December of 2016, CMS delivered it in the updated Workers' Compensation Medicare Set- Aside Arrangement (WCMSA) Reference Guide, Version 2.6 published on July 10, 2017. In addition to the establishment of an amended re-review process for a certain set of cases, CMS also added a section on the impact that state specific statutes will have during its review of WCMSA submissions. Additional revisions included an expanded “hearing on the merits” section, the introduction of a new pricing model for spinal cord stimulator projections and the establishment of a new claim reopening process. Given the substantive changes to the Reference Guide, the wait was well worth it. Details regarding the specific changes may be found in our prior blog.
The MSP industry also received the benefit of the California Insurance Guarantee Association (CIGA) v Burwell, et al case in the U S. District Court for the Central District of California ( 2017 U.S. Dist. LEXIS 1681 (January 5, 2017). The CIGA action stemmed from CIGA's objection to CMS's three reimbursement demands for payments made on service dates that included both work related and non-work related treatment charges. Although CMS subsequently dropped the demands, CIGA sought a judicial declaration and permanent injunction barring CMS from calculating conditional payments in this way. CIGA argued that this practice was contrary to the MSP and Medicare's regulations. In rejecting CMS's motion for summary judgment and defenses, the Court held that when a single charge contains multiple diagnosis codes, the presence of one injury related code does not “ipso facto” make CIGA responsible for full reimbursement of the non-industrial codes. The ability to reasonably apportion between the work related and non-industrial codes in the charge should be considered by CMS. NuQuest has had great success with citing this case in our conditional payment dispute negotiations.
CMS's potential review of Liability MSA and No Fault MSAs remained an item of interest in 2017. When seeking a new Workers' Compensation Review Contractor, CMS included a request that the contractor also be able to review liability and no-fault MSAs. The Request for Proposal noted that the review process for the liability and no-fault MSAs may begin as of July 1, 2018. CMS Manual System update issued on February 3, 2017 confirms that as of October 1, 2017, CMS' Common Working File will reflect the existence of a liability MSA or no-fault MSA in its system. Medicare Administrative Contractors will be instructed to deny payment of any submitted claims that pertain to the liability or no-fault MSA.
As we look to the year ahead, we will see the implementation of the Social Security Number Removal Initiative beginning in January of 2018. We will also see the, Performant Financial Group take over as the new Commercial Repayment Center contractor as of February 9, 2018. Updates on these changes will be provided.
(As published in a recent NuQuest newsletter)
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