Introduction to WC

Many people have asked me for the basis of CMS' authority to get involved with workers' compensation claims. Go here: Introduction to WC to read CMS' explanation.

Neurontin and Ophthalmology visits

Last year MSA allocators learned that the WCRC was adding Ophthalmology visits for claimant who were taking the prescription drug Neurontin. This had the allocators confused becuase there was no widely published literature about why Ophthalmology visits were related to taking Neurontin. Leave it to the WCRC to find some obscure medical report that linked the long term use of Neurontin to eye problems. Did the CMS place anything in the public domain alerting allocators of this requirement? Of course not. So the only way we learned about this was getting an allocation back with a higher figure due to the added expense of the Ophthalmology visits.

But we have just learned that is no longer a requirement. We have a source that used to work high up in CMS. We were told that CMS told the WCRC to stop this requirement by way of an internal memo. Were we told of this by CMS? Of course not.

CPT Codes

Getting the correct CPT code for the right procedure is critical. CMS, of course, does not include CPT codes when it demands a higher amount for an MSA. CMS instead provides generic labels for the individual allocation items like: Lab Work, Physician Visits, MRI. This makes it very difficult to determine where you went wrong with the allocation and even more difficult to correct your mistake in the future since you cannot identify it.

We have been told that CMS does not provide the CPT codes because its subcontractor is not paid to provide CPT codes. This is very inefficient and does not help the allocators at all.

Pricing Prescription Drugs

There is no doubt that adding prescription drugs to MSAs as of 1/1/2006 has added to the allocations considerably. CMS currently does not have a system in place for checking the accuracy of prescription drug portion of an MSA. See CMS Policy Memo Dated July 24, 2006 (question #13). It is our understanding, based on conversations with various CMS representatives, that it does not intend to implement one in the near future. so for now, CMS will continue to accept an MSA proposal where it appears that a"good-faith" effort was made at pricing the prescription drugs. Keep your eyes on this issue because if it changes it could dramatically change how MSAs are priced.

The COBC

According to CMS' website:

All Workers' Compensation (WC) occurrences that involve a Medicare beneficiary
should be reported to the Coordination of Benefits (COB) Contractor. If you
would like to report a WC case, obtain conditional payment information, or have
a general WC question, please contact the COB Contractor by phone or mail.
Customer Service Representatives are available to provide you with quality
service Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except
holidays. The COB Contractor's toll free number is 1 (800) 999-1118 or TTY/TDD: 1 (800) 318-8782 for the hearing and speech impaired.

The COBC is the entity to which you are required to submit a conditional payment request or a WCMSA proposal. However, the COBC has nothing to do with processing the WCMSA or the conditional payment request. Read that again: The COBC does not do any of the processing. All the COBC does is enter information into a central computer system, transfer any paper file to a digital image, and then submit the request to another entity for the processing.

I have had very little or no success in obtaining any useful information from the COBC. For conditional payment information I would suggest contacting the MSPRC: 866-677-7220. For WCMSAs, contact your regional CMS office. Click here for a listing of offices.

Delay in processing conditional payments

Since Oct of 2006, the MSPRC has been trying to image 450,000 files that it took over from prior companies that were doing the conditional payment (CP) processing for CMS. This has caused significant delays in obtaining conditional payment information. I have spoken with MSPRC representatives frequently and find the whole process maddening. Very little of how the MSPRC process conditional payments make sense. For example, even though I send a letter requesting the conditional payment status with the appropriate consent form, the MSPRC does not process my request until I make a follow-up phone call requesting the information. Each phone call takes at least 10 minutes and very few of the MSPRC representatives are trained to handle CP questions.

So be prepared to encounter many obstacles in trying to obtain CP information.

Let's get started

This is my first post and thought we should explore the world of conditional payments. Technically, these are not related to MSAs, but are lumped together with MSAs because they involve Medicare and worker compensation (WC) claims.

While an MSA is a vehicle to protect Medicare from having to pay for medical costs after a WC case settles, conditional payments are medical costs improperly incurred by Medicare before the WC case settles. To properly settle a WC case both the MSA and conditional payment status should be addressed with CMS. For more info click here.