CMS issues WCMSA Reference Guide Version 2.4
Heather Sanderson
February 2, 2016

We now have the third version of the WCMSA Reference Guide; however, the Reference Guide remains entirely the same with the exception of one addition.  The one change is the addition of the following to section 2.2: “Note: If Medicare is pursuing recovery directly from the WC insurer, the beneficiary, attorney or other representative will receive a copy of recovery correspondence sent to the WC insurer. For more information on insurer recovery, see the Non-Group Health Plan Recovery page: http://go.cms.gov/NGHPR.” The updated WCMSA Reference Guide can be found here.

Commentary: It is interesting to note that the one update to this WCMSA Reference Guide is not actually about WCMSAs, but pertaining to changes to the conditional payment correspondence process instead. This is a pretty strong example of where the major changes are happening within MSP compliance right now- CMS is in the process of rolling out some major changes to its conditional payment processes but has left the WCMSA process mostly unchanged as of recent. Additionally, the current WCRC contractor that reviews WCMSA is currently producing a very low turnaround time of 25 days.

With regard to conditional payments however, as of October 1, 2015 the Commercial Repayment Center (CRC), began to co-exist with the BCRC with its main focus on pursuing conditional payment recovery where the insurer is the debtor and CMS first receives information about the claim via Section 111 reporting. The CRC is pursuing recovery on cases where Ongoing Responsibility for Medical (ORM) exists and therefore is not bound to recovering only when a settlement, judgment or award occurs- it can recover at any time after an RRE reports ORM.

The CRC is pursuing recovery on open ORM cases through the issuance of a Conditional Payment Notice (CPN), which must be responded to within 30 days or CMS will issue a Demand and interest will be assessed if not re-paid within 60 days. An RRE with ORM outstanding may see several CPNs over the life of a claim. With regard to this update in the Reference Guide, CMS is letting the industry know that even though the insurer and CRC may be driving the ship, the beneficiary will have insight into the process and will receive copies of all correspondence.

For more information on the CRC and recent conditional payment changes, we recommend that you catch up on our latest webinar “120 days Post CRC Go Live Where do We Stand” by clicking here.

Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP
Chief Legal Officer
Franco Signor LLC