CMS Issues WCMSA User Guide 2.2 Today
June 3, 2014

Written by: Steve Shamrock, VP of Operations, Clinical

Today, the Centers for Medicare & Medicaid Services (CMS), in an effort to improve the WCMSA process, updated its user guide.  A catalyst for the release, was concern over the increase in development letters and requests for additional medical records.  While Franco Signor did not experience this problem to the degree and severity expressed by others, we applaud CMS’ effort to clarify its processes.  We will implement any notable changes into our program immediately to increase the benefit for our clients.

Section 10.7 of the user guide changed slightly with regard to the submission of medical records.  It now reads:  Include [with your CMS Submission]…the last two years of treatment, no matter how long ago those last two years were or who paid for the services.”  An example is provided by CMS regarding a submission made today, where the last treatment occurred in 2006.  To avoid a development letter, medical records must be provided for the period 2004 – 2006.  A statement that treatment has not occurred for the last two years would be unacceptable.  While the language has changed from the original text of:  “If you believe the last two years of treatment are unrelated to the work injury, send those medical records in addition to those related to the work injury, along with any explanation you believe is necessary.”  We don’t believe the outcome will be any different.  The changed wording is not limited to medical treatment “related to” the workers’ compensation injury, but any treatment that was provided.  We suspect the change was to clarify the impossibility to provide medical records when no treatment has in fact occurred, which makes sense.

Another important change to the program was the new added Section 4.1.4 on Hearing on the Merits of the case.  The legal compliance component is increasing as the Medicare Secondary Payer Law develops in the courts.  A hearing on the merits can drive outcomes for a WCMSA, so long as Medicare’s interests are adequately protected.  Our team of legal professionals stand ready to demonstrate how this new feature can be leveraged to bring certainty to a workers’ compensation settlement.  As our team is embedded with our clinical professionals, we review every WCMSA for important legal exceptions.  Aside from these two important changes the CMS also included updates on:

    • Removal of the reference to Drug Tables for physician-dispensed drugs
    • Combined sections on Drug Tapering and Drug Weaning
    • Added Wisconsin to the list of states with no WC fee schedules
    • Added Appendix 6, List of Previous Version Changes

In conclusion, while the WCRC recently reviewed and approved thousands of WCMSAs in an expedited manner, we don’t believe that vendors who continue to submit WCMSAs without required documentation will have much success in the future.  Complete WCMSA Submission packages, those that are not rushed by arbitrary submission promises and/or the vendor’s desire to generate revenues, will continue to yield lower development letter requests.

Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide