CMS/WCRC Backlog Tops 10,000 Cases

Medicare Set-Aside Blog on August 15, 2011 | Posted by

While the WCRC and CMS is mum on why the approval process is taking an average of 180 days, everyone in the MSP industry knows that turnaround times are unacceptably long given the historical average of 90 days over the last year or so. What is really going on?

After an extensive review of our CMS submission metrics, RO response times, and extrapolation of the data into a market aggregate, we believe CMS is currently sitting on as many as 10,000 WCMSA cases in their review pipeline. The bad news is that this number seems to be growing with each passing day.

I previously postulated that the change in the WCRC contract was to blame for the slow turnaround. The currently vendor has been working through a series of 90 day emergency extensions since last October while a new 8(a) contractor could be selected through the burdensome federal procurement process. Then, after CMS awarded a new contract, there was a subsequent bid protest that further delayed the transition. That protest has since been dismissed, so hopefully the new contractor will get into place and begin work.

However, the current problem seems to be one of increased review requests coupled with inadequate funding under the original contract. As the volume of CMS approval requests has increased over the past five years, the staff at the WCRC has remained relatively static. So each month that goes by, a bigger hole is being dug with no concrete plans to dig out of the mess other than an unrealistic hope that the new contractor can somehow do a better/faster job than their predecessor. The work can be done better, or faster, but usually not both at the same time. Who thinks we  need lower quality reviews  in the name of more expedient results?

So what could CMS do to solve this untenable problem and get the wheels of justice flowing more smoothly? As I see it, there are only a couple of realistic and common sense options. If I were Gerald Walters, Frank Johnson, and Barbara Wright, I would either (1) increase the review threshold to $100,000 or (2) rubberstamp all pending submissions and start with a clean slate for the new contractor . (According to one former CMS source, this method has been employed in the past). Either would take care of the immediate problem, but would not address the long term problem.

What should be done to solve this problem once and for all? Do away with the review process altogether, and certify independent MSA providers to create CMS-compliant MSAs. They could hire a RAC contractor to audit a subset of all MSAs created and revoke certifications of vendors who fail to comply with their policies. Cases could settle within a week, vendors would be kept honest by the threat of losing their CMS certification, and only a small fraction of cases could be targeted for enforcement at a fraction of the cost of the current review program.

Why hasn’t CMS called and offered me the job of MSP Czar?


Check our estimate using this formula and email me if you get a different number.