The new WCRC, Capitol Bridge presented a short transition webinar this afternoon. The main presenters were Holly Havens of Capitol Bridge and John Jenkins of CMS. Ms. Havens stressed the group’s 25 years of experience in providing various support services to CMS. The group intends to maintain the same level of quality and timeliness with processing the files. According to their Statement of Work, development letters, if any, will be sent out within the first 10 business days after receipt of the CMS submission. Determinations will be issued within 20 business days after the complete submission is received. Files that are currently pending will be transferred over to Capitol Bridge as of March 19, 2018, their first full day. There will be no change to CMS’ projection methodology.
Customer service will be handled by Capitol Bridge’s staff in Pittsford, New York. The preferred method of contact is by telephone, (833) 295-3773 or by email at WCRC@capitolbridgellc.com. All forms of communication must include the claim’s specific case number. Claims should continue to be submitted through the portal and to the same mailing address in Oklahoma. Capitol Bridge’s fax number is (585) 425-5390.
A question and answer session included questions regarding possible liability and no-fault MSA review. John Jenkins declined to address these during this call. Other questions focused on a concern about a backlog given the transition and the qualifications of Capitol Bridge’s reviewers. No backlog was anticipated by Capitol Bridge. Their review staff was also described as experienced MSA nurse reviewers, MSP compliance attorneys, physicians, and pharmacists. Capitol Bridge’s goal is to automate as much of the process as possible to avoid double keying of information and better coordinate the exchange of data between various systems. The portal user interface will not change as a result of the transition. Capitol Bridge also indicated that their 20 business day turn-around time should also apply to the amended review process. This presentation will also be available in the near future on CMS’ “What’s New” section on their website.
We will continue to keep you advised of further developments.
CMS just announced its plan to host a webinar on March 7th, 2018 at 1:00 pm ET to introduce the new WCRC Contractor. The new contractor, Capitol Bridge LLC, is expected to assume responsibilities on March 18, 2018. Registration and webinar login URL is https://engage.vevent.com/index.jsp?eid=5779&seid=863 with a conference call number of 877-251-0301, conference ID 9369188.
We will keep you advised of further developments.
Life expectancies play a significant role in future medical treatment projections. CMS announced on the WCMSA portal page, that as of December 11, 2017, CMS will look to the 2014 CDC Life Tables for the total population in determining life expectancy calculations. The CDC 2014 Life Tables can be found at https://www.cdc.gov/.
The Centers for Medicare and Medicaid Services (CMS) continues to consider expanding its voluntary Medicare Set-Aside Arrangements (MSA) review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS will work closely with the stakeholder community to identify how best to implement this potential expansion of voluntary MSA reviews. Please continue to monitor this website for updates and announcements of town hall meetings in the near future.
CMS issued an updated WCMSA Reference Guide, Version 2.6 (Guide) on July 10, 2017. The “State-Specific Statutes” provision under Section 9.4.5 Medical Review Guidelines notes CMS’ willingness to recognize WC state-specific statutes with the important caveat that “the submitter has demonstrated that Medicare’s interests have been adequately protected.” If a state-authorized utilization review board varied the treatment recommendation, CMS requested that the submission include an alternative treatment plan to replace the treatment deemed unnecessary by the utilization review board. Failure to include an alternative treatment plan would result in CMS reverting to its traditional projection model. The “State –Specific Statutes” provision also noted that submissions based on state-legislated time limits must be supported by a finding from the appropriate court or state entity that the specific case “does not meet the state’s list of exemptions to the legislative mandate.”
State-specific requirements and the criteria that must be met for the amended review are further discussed in Section 16.0 “Re-Review.” The Note under this section specifically states: “In the event the treatment has changed due to a state-specific requirement, a life-care plan showing replacement treatment for disallowed treatments will be required if medical records do not indicate a change.”
Recent CMS determinations and our CMS communications are providing data on CMS’ interpretation of the above provisions. The most significant change that we have seen involves the Independent Medical Review (IMR) in California. The IMR determination, if unchanged on appeal, is deemed to be the determination of the Administrative Director (AD) on the issue and binding on all parties. In the past, CMS would defer to the findings of the IMR and exclude the denied treatment or drugs in question.
Since the updated Guide was put out, we have seen CMS include IMR denied care citing a lack of replacement treatment options. Further clarification noted: “The CMS position is not whether a carrier demonstrates liability, but whether Medicare would reasonably pay for something in the future that should have been covered as it related to the WC claim.” In situations involving denied treatment, CMS seeks an “alternative treatment that would be acceptable through the IMR process.” A position that no further care is appropriate appears unacceptable to CMS if the treating physician is recommending care.
In light of CMS’ current interpretation of the IMR and utilization reviews, submissions should include an alternative treatment plan. Although utilization reviews generally consider the medical necessity or reasonableness of a specific treatment, the replacement treatment for disallowed treatments can be provided by the AME/PQME physician or by a different type of “state-authorized” utilization review board. Replacement treatment plans may also look to state specific medical treatment guidelines for the conditions. Opting out of the voluntary CMS review process also remains a viable option. We will keep you advised of further developments.