On February 22nd, CMS issued a Request for Proposal (RFP) which invites bids for the contractor that reviews WCMSA submissions- also known as the Workers’ Compensation Review Contractor (WCRC). The proposal due date is April 8, 2016 and the anticipated award date is June 20, 2016. The RFP can be found here.
A new contractor reviewing WCMSA submissions could bring forth some temporary changes as the contractor gets settled in this coming June. The current WCRC contractor has been turning around WCMSA determinations in a timely fashion of 2-4 weeks on average. In addition to timely turning around WCMSA determinations, we have seen predictable outcomes resulting in higher first-pass approval ratings on our submissions with this WCRC. We attribute our current success with the WCRC due to our experience with their practices and having become skilled at navigating their process.
Notwithstanding our success with the WCRC, it is important to remember that the WCRC does not create its own guidelines. CMS creates the review practices and policies and the WCRC fulfills that aim by implementing CMS’ policy on how a WCMSA should be priced. Therefore, in theory, the new WCRC should operate on the same guidelines as the current WCRC.
While on the topic of CMS WCMSA review policies and guidelines, it’s worthwhile to think about the pros and cons of CMS submission. Some review practices overinflate WCMSAs unnecessarily, such as CMS’ refusal to allocate based upon nationally accepted evidence based medicine. Additionally, Average Wholesale Price (AWP) is a generally overinflated pricing mechanism for Part D Drugs. As a result, Franco Signor offers non-submission products for clients who feel AWP pricing is unsubstantiated and know that a “cut and paste” philosophy for lifetime medications is not reasonable.
With all of that being said, one major review practice of CMS does provide a serious discount to present value which is often not recognized: CMS prices lifetime medicals in the WCMSAs at rates available today without regard to medical cost inflation. This is one major cost savings that is often overlooked.
Submission of a WCMSA to CMS/WCRC has its benefits as well as drawbacks. Settling parties do have the option of protecting Medicare’s interests in their settlements without undergoing the voluntary submission process. Each settlement should be assessed based upon the specific facts, legal and clinical issues, and the parties’ appetite for risk. We will keep a close watch this coming June to see which entity wins the award and how it may affect current CMS review practices.
Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP
Chief Legal Officer
Franco Signor LLC