CMS Update – MSA Approvals Trickling In…. Slowly

Medicare Set-Aside Blog on November 5, 2012 | Posted by

On August 12, 2010, CMS released a request for proposal seeking a qualified 8(a) contractor to perform the services of the Workers’ Compensation Review Contractor (WCRC) in a one-year contract with four one-year options. The RFP required that all WCMSA proposals be reviewed within 20 business days of receipt, excluding those cases requiring development for additional information. The contractor has five business days to alert the submitter to any missing and/or inappropriate documents and 15 business days to complete the review after the missing documents have been submitted.

After the contract was awarded to Provider Resources in June 2011, one of the other bidders, Data and Analytics Solutions, protested the award, delaying the contract for a year. During that time, the previous contractor, Lifecare Management Partners, continued to process the cases while winding down its WCRC operations center.

On July 2, 2012, CMS finally replaced Lifecare Management Partners but required them to process all of the cases that were still outstanding as of June 30, 2012. At the time, we estimated a backlog of 10,000 claims remained with that contractor. Not surprisingly, the company is turning its focus to other service areas, and we are now seeing turnaround times of up to 365 days for certain outstanding cases.

The new contractor has shown a significant improvement in turnaround times. We’ve found cases submitted in July were reviewed within 45 days; however, for August, cases submitted that have been reviewed have taken an average of 50 days and a third of the cases submitted in August are still not approved.

As for development, it’s taken an average of 24 days to get requests, although some have come as quickly as a day. We have noticed a slight uptick in development requests, but often the contractor already has the information that they are seeking in the previously submitted record. One item that has become a big priority with the new contractor is the prescription history. They are insisting on an Rx history with every MSA, requiring a blank pharmacy printout as preferable to a drug questionnaire.

We’ve seen some inconsistencies between treatment requirements from the old contractor such as an increase in number of procedures over the claimant’s life expectancy as well as the number of physical therapy sessions. Not surprisingly, the new contractor still struggles with the off-label drug use issue.

In general, we believe the new contractor is doing their best to get the cases in and out as quickly as possible. We’ve found them to be willing to answer questions and rethink some decisions. Hopefully they continue to ramp up so that we don’t end up in the same situation as with the old contractor.

As for cases that remain with the old contractor, it seems that we must remain patient and hope that as the backlog dwindles, the speed of approval will increase.