On October 5, 2020, CMS issued a new WCMSA Reference Guide (Guide) version 3.2. Changes to the Guide include defining what major medical centers the Workers’ Compensation Review Contractors (WCRC) utilize for pricing surgical interventions in WCMSAs. A copy of the new Guide can be found here.
Specifically, CMS added a new Appendix 7 to the Guide which lists major medical centers organized by state, medical center name, National Provider Identifier (NPI) and zip code. CMS refers to this pricing methodology index when discussing WCRC Review Considerations in Section 9.4.3 of the Guide; Intrathecal Pump and Spinal Cord Stimulator pricing in Section 9.4.5 ; and for selecting the appropriate jurisdiction in 9.4.4 of the Guide. Some specific references are listed below.
- 4.3 WCRC Review Considerations
Hospital fee schedules are currently determined using the Diagnosis-Related Groups (DRG) payment for the median major medical center within the appropriate fee jurisdiction for the pricing ZIP code, unless otherwise defined by state law (see Appendix 7).
- 4.4 Medical Review Step 5: Verify jurisdiction and calculation method.
This process for selecting jurisdiction and determining pricing will also be used when determining ZIP code selection and which major medical centers to use for future pricing for WCMSA proposals (see Appendix 7)
- 4.5 Medical Review Guidelines
Intrathecal Pump Surgery/Procedure Pricing
Facility fee: DRG codes for inpatient procedures are priced for a major medical center in that state, unless the fee schedule has pricing for that DRG (such as Illinois) (see Appendix 7). If the procedure is an outpatient procedure, pricing is per the Ambulatory Payment Classification calculator for a facility in that state, unless the fee schedule has a maximum reimbursement amount for that procedure
Pricing for Spinal Cord Stimulator (SCS) Surgery
Facility fee: A DRG, or diagnostic related grouping, is how Medicare and some health insurance companies categorize hospital costs and determine how much to pay for a patient’s hospital stay. DRG codes for inpatient procedures are priced for a major medical center in that state, unless the fee schedule has pricing for that DRG (like Illinois) (see Appendix 7). If the procedure is an outpatient procedure, pricing is based on the Ambulatory Payment Classification calculator. This is the amount Medicare pays for facility outpatient services in that state, unless the fee schedule has a maximum reimbursement amount for that procedure.
The pricing tool for major medical centers is now accessible in the WCMSA Portal as well. These initiated changes will hopefully help enhance appropriate pricing for surgical interventions in the WCMSA and will provide more transparency in the WCRCs pricing process.
As this continues to develop, NuQuest will provide additional updates. In the interim, should you have any questions, or for any of your MSP compliance needs, please contact NuQuest Settlement Consultant team at: SettlementConsultants@mynuquest.com