CMS And WCRC Streamline Review Process To Clear Backlog

CMS, Medicare Set-Aside Blog, News and Events on May 13, 2014 | Posted by Jean S. Goldstein, JD

Over the past week, MEDVAL has received numerous calls from the CMS WC review contractor (“WCRC”) regarding closeout letters received in response to requests for additional information for many submissions. MEDVAL was advised that these closeout letters were apparently inadvertently issued, and that the WCRC was working with CMS to clear their backlog. We have all witnessed this backlog, in which the 30 day turnaround time, guaranteed by the CMS review contractor, became a 60+ day turnaround time, especially since numerous and burdensome developments were issued on nearly all WCMSA submissions.

Yesterday afternoon, MEDVAL began receiving CMS correspondence and determinations which were noted to be subject to a streamlined review process. Each CMS approval was accompanied by a cover letter indicating that the “WCMSA proposal submitted for the Medicare beneficiary/claimant named was subject to a streamlined review process. The Centers for Medicare & Medicaid Services (CMS) has accepted your proposal to protect Medicare’s interests with a WCMSA for future expenses related to [Claimant’s] work injury or disease.” The approval is also accompanied with both structured funding and lump sum funding instructions. Interestingly, many of the approvals received were in a development stage and had been closed out by the WCRC. Many of these cases were on hold and inactive with the WCRC based on prior requests for additional information, usually additional and unrelated personal medical records or prescription history information. MEDVAL has confirmed that the WCRC simply streamlined these reviews and approvals, despite the earlier demands for additional information required to review the case.

While some counter opinions were also issued yesterday, it appears that as indicated by the WCRC, both the WCRC and CMS are working diligently together to clear their backlog. We suspect that once the backlog has been cleared, reviews will continue pursuant to the guidelines outlined in the WCRC’s reference guide. The good news is that we expect the number of development letters to decrease, as the WCRC and CMS continue to work together to streamline the CMS approval process. MEDVAL has already seen significantly fewer developments for unnecessary and unrelated items being requested by the WCRC in the last two months.

MEDVAL will be expediting all of these determinations to our clients who have long been awaiting these determinations to avoid any further delay. We will also continue to monitor the streamlined review process to ensure cases submitted by MEDVAL have been properly reviewed.