Updates Added to the WCMSA Reference Guide

CMS, Medicare Set-Aside Blog, MSP News on January 7, 2015
Posted by Jean S. Goldstein, JD, CMSP

CMS issued an alert today that a revised version of the WCMSA reference guide has been released.  The revised guide, dated January 5, 2015, can be found here.

CMS also issued a revised Self-Administration Toolkit for WCMSAs, which can also be found here.  The Self-Administration Toolkit serves as a helpful resource for Claimants and provides information to Claimants as to how to manage their WCMSA accounts appropriately.

The revised WCMSA reference guide includes language to address the schedule change for hydrocodone compounds, based on the reclassification of hydrocodone compounds effective in October, 2014.  The WCMSA guidelines changed on January 1, 2015 for all new cases submitted after that date to allocate a minimum of 4 healthcare provider visits per year when schedule II controlled substances (including hydrocodone combination products) are used continuously, unless healthcare provider visits are more frequent per medical documentation provided with the submission.  As we previously reported, most recommended WCMSAs received from CMS have been allocating for physician visits on a quarterly basis.  As such, the inclusion of a minimum of 4 yearly healthcare provider visits has become the standard, even prior to the reclassification of hydrocodone compounds.

The revised reference guide also reflects an updated deadline response time to development requests in response to a WCMSA submission.  A submitter now has 20 business days, rather than the previously allotted 10 days, to respond to a development letter, or the case will be closed until additional information has been provided to address the development request.   While this extended time frame will certainly be helpful, we are still seeing many development requests still being issued by the CMS review contractor- far fewer than we have seen in the past- but still many developments on many cases.  With respect to developments, the most frequent reasons provided by the CMS review contractor, for which we continue to see developments are:

  • Non-current medical records being provided, per CMS’ guidelines, which do not include the last two years of records related to the industrial conditions.  CMS has continued to ask for more current records in many cases, even if the carrier has not paid for any recent treatment, such that CMS is essentially asking for non-injury related treatment records to be provided in many cases;
  • Insufficient payment histories, if the payment history does not provide a breakdown for medical, indemnity, or expenses categories for the last two years; and
  • Insufficient prescription history information, if the prescription history information provided does not reflect current medications or recent fills of medications.  In these cases, CMS has requested pharmacy printouts from all pharmacies where Claimant fills medications covering the last two years be provided, and which is to be dated within six months, even if the prescription medication treatment has not been paid for by the Carrier.

We continue to hope that the CMS review contractor will request only relevant information that is necessary to complete a review of a WCMSA proposal, rather than unrelated non-industrial medical information, such that development requests will continue to subside.

We will continue to monitor CMS trends and implementation of the guidelines set forth in the most recently revised WCMSA Reference Guide.