By Marty Cassavoy, Vice President of MSP Compliance, ExamWorks Clinical Solutions
Workers’ compensation practitioners with long memories can cite dates the way sports announcers remember games: Autumn of 2007, Summer of 2012, January of 2016. No, these are not dates tied to epic comebacks or long losing streaks. These are dates and times when the Centers’ for Medicare & Medicaid Services (CMS) employed new Medicare Secondary Payer (MSP) contractors.
CMS contractor changes have a significant, if temporary, impact on workers’ compensation claims handling. Recently, CMS announced that it will transition both contractors overseeing MSP compliance processes. What’s more, both transitions are expected to occur around year end. What does this mean for claims handling? What are some practical tips as we buckle up for this season of change?
Workers’ Compensation Review Contractor
The Workers’ Compensation Review Contractor (WCRC) reviews all workers’ compensation Medicare set-asides (MSAs) that are submitted for review and approval. Parties are not required to submit MSAs for review and approval, but CMS policy suggests it upon settlement with a Medicare beneficiary, and those who are soon-to-be Medicare beneficiaries. Provider Resources, Inc. (PRI) currently reviews MSAs and most practitioners have been pleased with its performance, especially with its ability to review cases quickly.
PRI assumed the WCRC contract in the summer of 2012. At the time, a poorly-conceived transition plan left thousands of MSAs in a state of limbo, ignored by the prior contractor, and outside the scope of PRI’s review mandate. Parties had to wait months for this response, and in many instances over a year. The cases languished and, eventually, CMS wound up “approving” all of the proposals without any independent review. Many settlements became stale or outright died due to the failed transition plan.
In September 2017 CMS awarded the WCRC contract to Capitol Bridge, LLC. That award has been protested by two runners-up, KEN Consulting, LLC and Arch Systems. Decisions on the protests are due in December. If the protest fails, and a new contractor does indeed come on board, parties will need to plan for possible speed-bumps in the transition process.
Commercial Repayment Center Contractor
The Commercial Repayment Center (CRC) recovers from workers’ compensation carriers and others, whenever a claims payer has identified itself as “responsible” to pay for a Medicare beneficiary’s ongoing medical treatment. The launch of the CRC’s “ORM” recovery on October 5, 2015 signified a shift in CMS’ conditional payment recovery policies. With the CRC, CMS now authorizes its contractors to recover mistaken Medicare payments from claims payers in near real-time, rather than waiting for settlement.
The CRC program remains a work-in-progress. Our webinar from earlier this month provides a great summary of how the CRC came about and chronicles its struggles. The CRC contractor, CGI Federal, struggled initially to get conditional payment correspondence out the door and into the hands of claims payers. The failure to issue these letters, often critical to any settlement involving a Medicare beneficiary, was so great that on February 9, 2016 CMS took the unprecedented step of releasing a public notice to ease concerns about the process. CMS’ alert explained that: “the CRC has issued more than 33,000 Conditional Payment Letters (CPLs) and Conditional Payment Notices (CPNs) since the transition. CMS is aware that many insurers and WC entities are awaiting CPLs, CPNs, or demand letters. CMS is engaged with the CRC to improve responsiveness to requests for conditional payment information and the handling of correspondence.”
The transition to the CRC proved challenging for claims payers, the CRC, and Medicare. Earlier this month CMS announced that Performant Recovery, Inc. would be the new CRC contractor. CMS’ announcement explains that Performant will take over in January 2018 and that: “[CRC’s] activities will be transitioned in a manner that preserves continuity and presents minimal disruption to the recovery process.” We can only hope.
What Workers’ Compensation Practitioners Need to Know
We are entering an unprecedented simultaneous MSP contractor transition. Given history, we can only hope that CMS will work with incumbent and new contractors to develop a well-coordinated transition plan that imposes little to no impact on claims payers and Medicare beneficiaries. ExamWorks Clinical Solutions has been through every contractor transition to date, and has successfully overcome the obstacles these changes present to claims resolution.
With that in mind, here are some key tips for resolving cases successfully when changes are pending:
- Be proactive. The devil you know is often better than the devil you don’t know. The existing MSP contractors offer relatively predictable processes, turnaround times and responsiveness. While no contractor is perfect, if you need to resolve a case involving a Medicare beneficiary in the near future, the existing contractors offer more certainty than a new contractor that may spend some time getting its sea legs.
- Anticipate issues and adapt as needed. To date, just about every MSP contractor change has come with one issue or another. Whether it is incredibly long turnaround times, inability to understand the nuance of workers’ compensation laws or good-old technical difficulties, something always happens. Develop a backup plan. If CMS and its new MSA review contractor fails to adequately prepare for the transition (as it did last time around), take steps to ensure that the case can settle without formal CMS approval if necessary.
- Pay attention to what’s happening. Experienced workers’ compensation practitioners know that MSP contractors impact claims payers on daily basis. Uncoordinated, dysfunctional contractors hamper settlement, add to claims costs and lead to misinformation and miseducation regarding MSP issues. The processes often do not work as intended by CMS and it is up to experienced MSP experts to explain what should happen and how it is different from what is actually happening. Contractor changes are not set in stone. The MSA contractor may change but it could also stay with PRI. CMS’ goal is to move the CRC over to Performant by January, but that may prove to be too ambitious.
Whatever happens, claims will be impacted. By having a well-coordinated and pliable strategy, claims payers should be able to contain any impact and resolve claims even as CMS simultaneously changes these critical contractors.
About Marty Cassavoy
Marty Cassavoy is the Vice President of MSP Compliance for ExamWorks Clinical Solutions (ECS). Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer (MSP) compliance and across all insurance types.
Marty is a frequent speaker, commentator and writer on all aspects of MSP compliance, where he is often unafraid to challenge the conventional approach to Medicare problems. Marty is a member of the ECS Leadership Team, providing strategic guidance for the organization’s MSP compliance products and services. In his day-to-day role, Marty leads ECS’s Compliance Team where he and his talented team collaborate to solve problems, react to industry changes and build innovative MSP compliance solutions.
Marty can think of no greater joy than helping insurance professionals conquer their fear of MSP compliance. His goal is to simplify MSP compliance and improve problem solving skills rather than simply present a laundry list of problems. With this aim in mind, Marty and his team develop engaging and informative MSP compliance educational programs for ECS’s clients.
Prior to joining ECS, Marty was Vice President of Policy at ISO Claims Partners, where he worked for more than a decade. Marty is a graduate of Boston University and Suffolk University Law School in Boston, where he graduated with honors. Marty is a lawyer licensed to practice in the Commonwealth of Massachusetts. Outside of the MSP compliance world, Marty can often be found at a baseball diamond, soccer field, basketball court or hockey rink where he is either watching or coaching one of his three talented children.
About ExamWorks Clinical Solutions
ExamWorks Clinical Solutions is the industry leader in Medicare Secondary Payer compliance, combining Medicare Set-Aside, conditional payment, and post-settlement services. The company provides comprehensive clinical mitigation programs and medical and vocational case management to insurers, self-insureds, and third-party administrators. ExamWorks Clinical Solutions, an ExamWorks Company, is headquartered in Lawrenceville, Georgia. Learn more at: www.examworks-cs.com.