Success in the CMS Re-Review Process

Pursuant to Section 16.0 of the Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide, Version 2.8, October 1, 2018, COBR-Q4-2018-v2.8, CMS will conduct a Re-Review of a prior WCMSA determination in certain circumstances.  Specifically, CMS will complete this process in cases involving a mistake in the allocation; mathematical error; or when there is missing documentation that pre-dated the WCMSA submission date that could change its value.  CMS will also perform an Amended Review when there are changes to the WCMSA that post-date CMS approval and the case meets certain criteria.  Knowing when and how to use the appropriate Re-Review process is imperative in helping to prevent inaccurate or over-inflated WCMSAs.

One recent example of NuQuest successfully utilizing the appropriate Re-Review option involved an appellate court order that was issued after the date of the WCMSA submission.  The case involved whether claimant required ongoing treatment for a work-related lumbar spine injury.  The appellate court determined that the description of injury was an aggravation of a lumbar sprain and claimant’s intervening injuries as well as a gap in treatment evidenced that claimant’s work injury had resolved.  Highlighting the timeline of the appellate process; the court’s rationale; medical evidence; and the nature of injury, NuQuest was able to successfully advocate for a zero dollar WCMSA.  This resulted in over an $18,000 savings to the client.

Critical review of a WCMSA to determine if a Re-Review is warranted is a necessary part of the Medicare compliance process.  However, identifying these issues is only one part of the equation.  Knowing the appropriate arguments to include in a Re-Review as well as the appropriate mechanism to make this request is equally important to obtain a successful result.

For further information regarding WCMSAs or any Medicare compliance needs, please contact the NuQuest Legal Team.

Client Realizes Half Million in Savings with NuQuest Re-Review

NuQuest strives to save our clients’ money, even years after the original settlement. One example is how a claim that was recently amended saved our client $567,706. Although the original CMS approval in January 2015 was for $780,736, a CMS Amended Review was requested by our client, due to a change in the treatment plan. Our updated review reduced the claim amount to $213,030, and the amended proposal was approved by CMS.

Our clients choose NuQuest as their trusted Medicare and MSP Compliance partner because we have a reputation for honesty and dependability. Over the years, we have assembled a core of specialists with industry-leading expertise in the areas of medicine, law and benefits. Contact us today to discover the NuQuest difference.

Commercial Repayment Center (CRC) Transition Webinar Available

In January, the Centers for Medicare and Medicaid Services (CMS) held a webinar discussing the transition of the Commercial Repayment Center’s (CRC) operating contractor from CGI Federal to Performant Financial Corporation for Group Health Plans and Non-Group Health Plans.  The slides for the webinars are now available on CMS’ website.  The Non-Group Health Plan presentation may be found here. The Group Health Plan presentation may be found here.

A summary of the presentation can also be found through our “Cases and Points Blog” or by clicking here.

Commercial Repayment Center (CRC) Transition Update:

The Centers for Medicare and Medicaid Services (CMS) recently held a webinar discussing the transition of the Commercial Repayment Center’s (CRC) operating contractor from CGI Federal to Performant Financial Corporation (Performant) for Group Health Plans and Non-Group Health Plans.

During the transition, there will be “dark days” where CRC will not be operating, but transferring files from CGI Federal to Performant.  These dark days begin on Friday, 2/9/2018 at 8 pm and end on Monday, 2/12/2018 at 8 am EST.  On 2/12/2018, Performant Financial Corporation will be operating the CRC.

Performant has provided two contacts for use with respect to the transition:

Ted Doyle – CRC Transition Project Director            Laura Martinez – MSP CRC NGHP Recovery Manager
(925) 337-5558                                                                  (209) 858-3705                             

Additionally, Performant has provided the following email to be used for claims with special needs:

Beginning 2/12/2018, all NGHP CRC correspondence and checks should be sent to:

Medicare Commercial Repayment Center – NGHP
PO BOX 269003
Oklahoma City, OK 73126

*New fax number (844) 315-7627

Fax Number: CRC’s current fax number will be disconnected on 2/6/2018 at 8 pm, the new number begins operation at 8 am on 2/12/2018.

Customer Service Line: telephone number stays the same (855) 798-2627. The phone line will be turned off at 8 pm on 2/9/2018.  Performant to begin its operation at 8 am on 2/12/2018.

All data is being “frozen” at the end of the day on 2/7/2018.  This means no new information or data will be uploaded onto the web portal or into CRC’s system until Performant starts entering the data on 2/12/2018 at 8 am.

All pending appeals will be transferred to Performant during the dark days, to assume handling.  The timeframe for response does not change and Performant requests the industry continue with their regular follow up time-frames.  (i.e. don’t call to see if an appeal with CGI was received by Performant).

Mail sent to the old CRC address will be forwarded to the new PO BOX, however, beginning 2/12/2018, the new PO BOX should be used.  If mail is sent to Performant before 2/12/2018, Performant will hold the mail and start processing beginning 2/12/2018 8 am.

Updated User Guide – Section 111 Non Group Health Plans, version 5.3:

A carrier or self-insured may have a responsibility to report to Medicare an Ongoing Responsibility of Medical (ORM) or a Total Payment Obligation to Claimant (TPOC) where there is a workers’ compensation or liability claim that involves a Medicare beneficiary. TPOCs usually are payments to a claimant after a settlement, judgment or award. These reporting requirements are commonly referred to as “Section 111” reporting.

The Centers for Medicare and Medicaid Services (CMS) provide a Section 111 Medicare Secondary Payer Mandatory Reporting User Guide for Liability, No-Fault and Workers’ Compensation claims (user guide).  This user guide discusses how Medicare expects ORM or a TPOC to be reported to Medicare through Section 111 reporting.  CMS recently published an updated version of the user guide, numbered 5.3, and a link to the updated version can be found at CMS’ website or by clicking here.

For background, the user guide has five chapters: I – Intro and Overview, II – Registration, III – Policy, IV – Technical Information and  V – Appendices. The 5.3 version provided updates to the following areas of the user guide:

  • Overall: Medicare will begin to use the Medicare Beneficiary Identifier (MBI) in its correspondences and query responses to parties instead of a beneficiary’s Social Security Number (SSN) or Health Insurance Claim Number (HICN). MBIs are being issued to Medicare beneficiaries as a part of the discontinuation of social security number based HICNs.
  • Data exchange escalation contact protocol (Chapter I, Section 8.2 and Chapter IV, Section 13.2)
  • Termination of Ongoing Responsibility for Medical (ORM) (Chapter III, Section 6.3.2)
  • ICD-10 exclusions (Chapter V, Appendix I and J)

Regarding MBIs, CMS has excluded the Medicare Secondary Payer processes from requiring stakeholders to exclusive use of a MBI.  This means, a claimant’s SSN, HICN or MBI will be accepted by Medicare for entitlement queries and matching data for submission of documentation and disputes. However, the parties should be aware that Medicare’s response may use the MBI, if available.  More about the Social Security Number Initiative and MBIs can be found here.

The data exchange protocol has now been amended to exclude contacting a particular employee within BCRC.  If there is a data exchange issue, the Responsible Reporting Entity (RRE) is to first contact their Electronic Data Interchange (EDI) representative (or contact BCRC to obtain one). If there is no response from the EDI representative within two business days, the RRE should contact the EDI Director, Jeremy Farquhar.  If Mr. Farquhar does not response in one business day, the RRE should contact the BCRC Project Director, Jim Brady. The contact information for these two individuals is located in the user guide.

Section 6.3.2, ORM Termination, was added to the user guide to include additional explanation of when termination of ORM may occur. CMS advises that when ORM ends, the RRE should report the date ORM terminated and not delete the record.  Additionally, termination of ORM does not require the reporting of a Total Payment Obligation to Claimant (usually settlements).

In sum, CMS states that ORM termination should be submitted where ORM is not subject to reopening or additional request for payment of medicals and one of the following criteria is met:

  • Termination of ORM can be reported where there is “no practical likelihood of associated future medical treatment and the RRE maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
  • Where insurer’s responsibility for ORM is terminated under applicable state law associated with the insurance contract; or
  • Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.”

Although the concept of ORM is not new to the industry, this new section of the user guide highlights the importance of an RRE’s protocol to determine: (1) whether ORM needs to be reported; (2) If ORM does need to be reported, what conditions should be reported; and (3) whether termination of ORM should be submitted.

Lastly, CMS has issued a list of ICD10 and corresponding ICD9 codes that will not be accepted by BCRC for section 111 reporting.  A full list of the excluded codes may be found at Chapter V, Appendix I and J of the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting User Guide, version 5.3, 12/15/2017.

We will keep you posted on more updates to the Section 111 user guide, as they are available.