i. Implant Policy. The policy is for the replacement, not the initial placement. Some submitters are not considering the initial placement. If it hasn’t happened yet, must include the placement in the first year.
ii. OTC vs. Prescription Strength: Issue raised on Ibuprofen which can be purchased OTC. John Jenkins clarified depending on mg level, if prescribed as 800mg, that is a prescription strength level and should be included.
iii. Discontinued Meds: MD no longer prescribing, for over 6mo’s and wondering why included? John Jenkins asked if the rx is still active/prescribed in the record? Patient non-compliance is not a reason to not be included in the MSA. If it’s something the provider is still prescribing, it’s to be included. Takeaway: confirm with provider if they are still actively prescribing or if the medication was discontinued and still reflected in medical records. Also include NDC codes. For opioids, following the opioid policy in the guide.
iv. TENS Units pricing- 2015 CMS put policy as investigational use. CMS dropped it 2019 moving it from Part B to DME schedule. Can be used as DME schedule regardless of if continued to be used or not.
v. Pricing for DME and labs where the state fee schedule is not covering it. CMS doesn’t dictate what pricing source WCRC has to use, just has to be industry standard. Reference guide talks more about Strataware.
vi. Possible vs. Probable treatment. Appearing absent reasonable expectation, WCRC including things not reasonably probable ( i.e. SCS, Pain Pumps, Surgeries). CMS expressed interest in evaluating this position; however, needs supporting evidence. Action: MSPN will work on securing evidence to further this conversation.
vii. Consent To Release concern. When injured workers review and sign these forms, it can be confusing. Action: MSPN evaluating the language to propose change with CMS. Terms such as “beneficiary” being changed to “claimant” or injured party.
viii. WCRC errors. John Jenkins advised most WCRC staff is same and continued over from previous contractor with no change in policy. John heard from WCRC, there may be new staff or interns with MSA vendors as the quality of CMS review packaging has reportedly dropped. Takeaway: if MSA vendors can review the WCMSA Ref. Guide, Section 10. Information Needed For WCMSA Submission.
ix. CMS Regional offices. CMS made a change in April, RO’s removed from the MSA determination process. Takeaway: CMS asks not to send information to the R.O.’s. Information can be sent through the mail (CD) or through the portal.
x. WCRC Turnaround Times. Per CMS, WCRC is reporting 7 business day turnaround. What we are seeing: 14 calendar day response for approvals, and 55 calendar days for approval following development request.
i. Recent clarification of Trigger for ORM Reporting in Chapter III of the NGHP User Guide (pertains mainly to No-Fault and Med-Pay). CMS expects the RRE will have performed its due diligence in researching a potential claim before assuming ORM. To report ORM, RREs must first assume the responsibilities for medicals related to the incident. The intention of this statement is to note that ORM should be reported as soon as possible by the RREs.
ii. Can Recovery Agents be copied on the ORM correspondence to beneficiaries? Status: We are providing examples of beneficiary notice to CMS for review.
“CMS appreciates the dialogue with MSPN, as it provides a mechanism to understand concerns and impacts as they relate to MSP policies and processes. This allows an opportunity to continually improve to meet the needs of CMS and stakeholders”. We are grateful for the relationship MSPN had developed with CMS over the years to participate in direct meetings and share our industry feedback.
