CMS “corrects” their review process of $0 set-asides in denied claims

Over the years, CMS has generally agreed that no WCMSA is needed in a denied claim that did not have any medical or indemnity payments made in it. This review process, however has now changed. According to CMS Health Insurance Specialists, CMS has decided to “correct” their review process so that it is consistent with the process outlined in the WCRC’s operating rules. In order for CMS to determine that no WCMSA is required in the denied claim, CMS will now look for the following: an absence of payments by the carrier and either a court order issued after a hearing on the merits that relieves the carrier of liability or a recommendation from the treating physician that no further injury-alleged care is required in the claim.

CMS’ decision to enforce this type of review for denied claims is likely to impact proposals that are currently under review and change the parties’ settlement negotiation strategy. Although we have asked CMS to advise the MSP industry of this new review practice and halt its application until notice is given, we have not received a reply.

We will keep you posted of further developments.

Leave a Reply