November Update to WCMSA Reference Guide; CMS to Host Section 111 NGHP Reporting Webinar
Today, the Centers for Medicare & Medicaid Services (CMS) published an updated version of the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide – Version 3.8, located here. The updated WCMSA Reference Guide adds an additional basis for re-review of a disputed Medicare Set-Aside (MSA) proposal, and it also adds a new section (Section 16.2) outlining re-review limitations.
New Basis for Re-Review
Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward.
· Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document.
Even though this new basis for re-review is only available for approvals dated September 1, 2022 and later, we are pleased to see such a fair and reasonable addition as a recognized “appeal” option. Mistakes happen, and thankfully CMS will be sympathetic to correctable mistakes that may occur during the submission process.
New Section 16.2
Re-Review Limitations Note: The following re-review limitations are only available for approvals from September 1, 2022 forward. Re-review shall be limited to no more than one request by type. Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error. Re-Review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.
Notably, the updated language states that “[r]e-review shall be limited to no more than one request by type.” In other words, a submitter is now limited to one “mathematical error” re-review request, one “missing documentation” re-review request, and one “submission error” re-review request per case file. We anticipate that CMS will also update its WCMSA submission portal to reflect this additional “submission error” option as there are currently only two options (mathematical error and missing documentation) available in the portal. Prior to this WCMSA Reference Guide update, CMS did not explicitly place a limit on re-review requests, so parties could have theoretically requested re-reviews an unlimited number of times. Now, parties will have a limited number of attempts similar to the limitation placed on Amended Review requests.
Section 111 Reporting Webinar
On Tuesday, December 6, 2022 at 1:00 PM EST, CMS will host a Section 111 NGHP webinar. According to the notice, located here, CMS will provide a presentation discussing NGHP reporting best practices and reminders followed by a question and answer session. We anticipate that CMS will remain silent regarding a publishing date for the proposed rule on Section 111 reporting penalties, but the MSP industry still expects a proposed rule to be published on such penalties within the next several months. Overall, the industry will appreciate any best practice tips as we near closer to civil monetary penalties for Section 111 errors and non-compliance.
At Sanderson Firm, we serve as a Section 111 reporting agent and consultative expert for workers’ compensation, general liability, and no-fault insurers. We also prepare and serve as a submitter for MSA proposals. For assistance with Section 111 reporting inquiries, Medicare Set-Aside, or any questions regarding this post, please do not hesitate to contact us.
