Contract for WCRC Contractor Capitol Bridge Renewed
By: Kristina Bonanno, Esq.
The Centers for Medicare & Medicaid Services (CMS) has renewed the contract for the incumbent Workers’ Compensation Review Contractor (WCRC), Capitol Bridge, LLC. The WCRC is the entity within CMS that reviews Medicare Set-Aside (MSA) proposals and the contract renewal is for another five (5)years, through 2028. CMS typically issues a request for new contractor proposals approximately every five (5) years. A request for proposal (RFP) for the WCRC Contractor was issued in 2022; however, CMS has elected to continue with Capitol Bridge, LLC, which has been the WCRC contractor since 2017.
This marks the first time that CMS has elected to continue with a WCRC contractor after the initial contract period has ended. Previously, CMS had replaced the WCRC contractor each time the contract has come up for bid in the past. The benefit of the current contractor remaining in place is that this removes the uncertainty of having an adjustment period that comes with a new contractor. With Capitol Bridge staying on, we do not anticipate any major changes to the current submission review process.
Over the last 5 years, Capitol Bridge has maintained relatively short turnaround times for approvals of submitted MSAs where no development letter is issued. However, there have been some other notable changes in determinations handled by Capitol Bridge in the last few years, including an increase in urine drug screens, the inclusion of Lyrica and other medications for off label use, and an increase in “possible” surgeries being included. As CMS does not always announce policy changes immediately, often the first indication of new allocation guidelines will come from the determination letters issued by the WCRC.
During the RFP period when the contract for the WCRC was up for bid, part of the provisions in the Statement of Work under the new contract noted that the WCRC could be expected to participate in 2-3 presentations per year at CMS’ direction. We have learned that CMS does not have a specific schedule related to outreach and education, nor does CMS expect one any time soon, but they reserve the right to exercise this option with the WCRC contractor.
Another point of interest in the RFP was a provision that mentioned that Liability Medicare Set-Asides (LMSAs) could be part of the scope of files submitted for review starting in 2024 with an estimate of 1,000 LMSA submissions per year. No further information on possible submission thresholds or standards of review for LMSAs has been provided by CMS. CMS has long alluded to reviewing LMSAs; however, no formal policy or standards for review have ever been published.
CMS withdrew its latest Notice of Proposed Rulemaking regarding LMSAs in October 2022 leaving the September 30, 2011 CMS Memo (The Benson Memo) as the only written guidance for LMSAs. The Benson Memo only provides the one exception where an LMSA is not needed, if the treating physician can certify in writing that the plaintiff does not require future care related to the injury. We will be interested to see if CMS finally commits to a review policy for the submission of LMSAs and how the WCRC contractor would implement these LMSAs reviews.
Sanderson Firm’s team of experts will continue to evaluate determination letters from the WCRC for trends and willchallenge determinations when necessary. If you have any inquiries or concerns pertaining to submission of an MSA, the WCRC contractor, or any other matters related to Medicare Secondary Payer (MSP) compliance, we encourage you to reach out to us.
