legacy claim solutions

Greg Gitter Offers Thoughts on CMS Re-Review Policy

Our very own Greg Gitter was recently interviewed as part of an article by our good friends at WorkCompCentral regarding some of the positive and negative effects of the Medicare Set Aside (MSA) re-review policy set forth by the Centers for Medicare and Medicaid Services two years ago.

 In 2017, CMS opened the door for a one-time re-review of an MSA provided the revised approval would result in a change to the MSA of at least 10% or $10,000, whichever was greater. Prior to this policy, CMS would only review and approve an MSA one time which could often leave settlement parties with no recourse if the approved MSA figure did not line up with the terms of their agreement.  In those instances, a decision was typically made to leave the file open and no longer pursue a settlement.  

 This policy change has been met with mixed results from our vantage point here at Legacy Claim Solutions. We often see instances where there have been drastic changes in treatment and medications subsequent to a CMS approval.  Previously those changes were irrelevant as the CMS approval was set in stone, however there is now an opportunity to position a file for a re-review which can re-open the door to negotiations and settlements, and we have had success with this process.  However, as the article states, parties must keep in mind the timeframe allowed for the one-time re-review.  In addition to the dollar or percentage requirement, an existing MSA approval must be between 12 and 48 months old to qualify.  Unfortunately, this stipulation eliminates many older files from the re-review consideration even though the treatment has changed dramatically.  We would like to see the timeframe requirement expanded to give these older MSAs an opportunity to be updated with current medical and prescription needs.  This would undoubtedly open the door to settlements on older cases that had been written off years ago.

 Overall, however, this has been a welcome change to the stale review policy that had been in place for years.  It is evident that CMS wants to work with the settlement community to improve the Medicare Secondary Payer compliance system when changes are needed.  We applaud the National Alliance of Medicare Set Aside Professionals (NAMSAP) for continuing their efforts to serve as the voice of the MSA industry.

 Please click here to visit our friends at workcompcentral.

Article Details Evolving Trends in Catastrophic Workers' Compensation Claims

We ran across an article by Insurance Business recently that details some evolving trends in catastrophic workers’ compensation cases.  We took a particular interest in this because while not all of the cases we assist in settling are catastrophic in nature, many of them are, and maintaining a keen understanding of the trends within the workers’ compensation industry helps us to better understand our client’s current approach to settling claims.  

 The article indicates the soft market experienced by the workers’ compensation industry over the last several years may be reversing.  There are a variety of factors that contribute to the current landscape of catastrophic workers’ compensation claims, including injury frequency, escalating costs of medical goods and services, and the advancement of modern medicine and procedures that prolong the life of injured workers.

 In our experience, these types of trends can elevate the status of a workers’ compensation claim from “standard” to “legacy” quick, fast, and in a hurry.  It simply becomes less and less advantageous to settle a claim when projecting the escalating costs of medical needs over one’s lifetime. It is imperative to get out ahead of these claims and implement mitigation strategies to help resolve them once and for all.  We are here to help bridge the settlement gap and assist our clients in tackling these difficult to settle cases in their entirety.

 Again, our thanks to Insurance Business for a very informative article that can be read by clicking here.

CMS Rings in the New Year with an Updated WCMSA Reference Guide

The Centers for Medicare and Medicaid Services (CMS) wished us all a Happy New Year by releasing the latest version of the Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide on January 4, 2019. The noted updates are as follows:

·     To eliminate issues around Development Letter and Alert templates auto populating with individual Regional Office (RO) reviewer names and direct phone numbers, these will now display the generic “Workers’ Compensation Review Contractor (WCRC)” and the WCRC customer service number “(833) 295-3773” (Appendix 5). 

·     Per CMS’ request, certain references to memoranda on cms.gov have been removed. 

·     The CDC Life Table has been updated for 2015 (Section 10.3). 

·     Updates have been provided for spinal cord stimulators and Lyrica (Sections 9.4.5 and 9.4.6.2) 

While the above bullet points are specifically highlighted as updates, it is worth mentioning that there are several instances within the WCMSA Reference Guide where CMS highlights the fact that the submission of a Medicare Set-Aside (MSA) to CMS for approval is a voluntary process. However, the WCMSA Reference Guide goes on to indicate that receiving CMS approval of an MSA is “the only process that offers both Medicare beneficiaries and Workers’ Compensation entities finality, with respect to obligations for medical care required after settlement, award, or other payment occurs.”  While, the workers’ compensation settlement community continues to explore alternatives to CMS approval including Evidence Based Medicine (EBM) MSAs, and other non-submission programs, the goal of these approaches should always be to avoid shifting the burden of paying for post-settlement treatment to Medicare.  

To view the updated WCMSA Reference Guide in its entirety, please click here.