Medicare & Workers’ Compensation Jonella Windell Centers for Medicare & Medicaid Services (CMS)

What’s New WCCCS Web Portal Workers’ Compensation Case Control System New Workers’ Compensation Review Contractor (WCRC) effective July 2, 2012 Policy Changes/Updates – TENS Units no longer covered for Chronic Low Back Pain 8/1/12 Policy Memorandum – Circumstances for re-review defined SMART Act of /01/20132

WCCCS Web Portal Allows submitters to download WCMSA proposals and associated documentation directly to the WCCCS Submitters receive alerts if required documentation is missing Submitters receive letters via the WCCCS on the same day (hardcopies are also mailed) Users must register – see instructions on the website at Benefits/WorkersCompAgencyServices/WCMSAP.html 03/01/20133

New Workers’ Compensation Review Contractor (WCRC) Effective July 2, 2012 Provider Resources, Inc. phone: fax: Submissions and correspondence still sent to same address: CMS c/o COBC PO Box Detroit, MI /01/20134

New WCRC Impact on Submitters/Claimants – Reduced turnaround time (clean/complete submissions reviewed w/in 90 days) Existing Backlog on Web Portal approved through one time streamlined process – May notice that pricing is different 03/01/20135

TENS Unit for Chronic Low Back Pain (CLBP) June 8, 2012, CMS Decision Memo stated that Medicare would not longer cover a TENS unit for CLBP August 1, 2012, Policy Memorandum – WC cases settled prior to 6/8/12 - CMS will consider TENS units for CLBP appropriate use of WCMSA funds – Cases settled after 6/8/12 – CMS will not include pricing for TENS unit in WCMSA approval amount 03/01/20136

WCMSA Re-Review CMS Approval letter is not an “initial determination” and is not appealable Parties may request a re-review if the claimant or submitter believes that CMS’ approval: – Contains obvious mistakes, such as mathematical errors or incorrect review of submitted records – Misinterpreted evidence previously submitted – Did not consider records or medical opinions dated prior to the date of CMS’ approval – Or, when there is a ruling by court of competent jurisdiction based on the merits 03/01/20137

SMART Act Strengthening Medicare And Repaying Taxpayers (SMART) Act [H.R. 1845] signed 1/10/13 – Highlights include: Web portal for conditional payment and demand amounts Appeal rights for insurers (where insurer is debtor) Medicare can establish reporting threshold Medicare cannot recover after 3 years from the notice of settlement Mandatory Insurer Reporting fines are discretionary Stay tuned…… 03/01/20138

What’s Not New Medicare’s Interest in WC cases 03/01/20139

Medicare’s Interest Past – Recovering mistaken and conditional primary payments – Medicare Secondary Payer Recovery Contractor (MSPRC) Present – Avoid making incorrect primary payments – Coordination of Benefits Contractor (COBC) – MMSEA §111 – Mandatory Insurer Reporting Future – Workers’ Compensation Medicare Set- Asides (WCMSA) – Workers’ Compensation Review Contractor (WCRC) – Regional Offices 03/01/201310

MSPRC MSPRC – NGHP PO BOX Oklahoma City, OK Fax: /01/201311

COBC Maintains the Common Working File (CWF) Responsible for Mandatory Insurer Reporting data processing Should be an attorney’s first contact with Medicare* (800) CMS Claims Investigation PO Box Detroit, MI NOTE: this address not for WCMSA Submissions 03/01/201312

WCMSA Basics WCMSA funds should be sufficient to last the remainder of the claimant’s estimated life expectancy (unless documented otherwise). WCMSA funds may ONLY be used to pay for injury- related services that would otherwise be covered by Medicare. 13

CMS Review of WCMSA is Recommended When: Claimant is currently entitled to Medicare (Part A, Part B, or both) and the total settlement amount >$25,000 Claimant is reasonably expected to become entitled to Medicare within 30 months and the total settlement amount >$250,000 NOTE: Review thresholds are not intended to create a safe harbor. Parties should consider Medicare’s interest regardless of CMS review. 14

Denied or Disputed Liability CMS will approve a “Zero ($0) Set-Aside) when: – Carrier has not made any indemnity or medical payments on the claim – Medical documentation demonstrates that no future treatment needed and settlement does not include money for future medicals – Court of competent jurisdiction has ruled on the merits of the case that carrier is not responsible for treatment related to the claim 15

Resources CMS’ WCMSA webpage – CMS’ Mandatory Insurer Reporting webpage – Benefits/MandatoryInsRep/index.html?redirect=/MandatoryInsRep/ Benefits/MandatoryInsRep/index.html?redirect=/MandatoryInsRep/ 03/01/201316

Seattle Regional Office Contacts Jonella Windell Tina Dickerson CMS Seattle Regional Office 2201 Sixth Avenue, RX-46 Seattle, WA Fax: /01/201317