CMS Review: Turnaround Times, Records Review, and Denied Claims

Uncategorized on June 29, 2012
Posted by Louis Jordan

Turnaround Times and Contractor Transition

In a conversation in late May, Frank Johnson, Health Care Specialist with CMS, indicated that the turnaround time for an MSA to be reviewed was at least 90 days, but that he did not have the number of cases currently in the backlog. He noted that the transition from the old contractor to the new one was still in progress and that he did not have an indication of when this transition would be complete, although we are expecting it to be completed next week. A review of the turnaround times that we are seeing is closer to 200 days.

Records Required for Review

Early this quarter Michael Berkey, Project Director for the WCRC, confirmed that CMS only requires the last two years of records for work-related treatment (as strictly as from a last visit in 10/2011 would only require records after 10/09), but he did qualify this with an understanding that this must actually be the last date of treatment and a “quality over quantity” caveat.

He noted that one single record would even be enough in the instance that the most recently treating doctor has performed a thorough examination and provided a comprehensive report. Further, he stated that he would not anticipate any development issues if we provide the first report of injury, records of all major surgeries, and the last two years of treatment in the vast majority of cases.

We requested his opinion as to whether it would be reasonable enough to rely upon the Carrier’s payment history and provide the preceding two years’ worth of records. He indicated that this is reasonable, but this method won’t prevent development requests if the Carrier has simply stopped paying for treatment and it is clear by the records that the individual continues to treat.

As a suggestion and in line with what CMS is currently requesting, they would want to use a pharmacy printout as a road map. CMS recognizes that the pharmacy printout often includes medications that are unrelated to the work injury, but this (according to him) is the most comprehensive record that shows who the doctors are, how often the individual is treating, etc.

All in all, Mr. Berkey promoted a subjective element to the review which, of course, (in typical CMS-fashion) gives them complete discretion over the review process.


Return to the July Newsletter