| Recently, Medical Settlement Specialists, along with carrier MSA venders and other entities dealing with MSA submissions, have noticed a significant increase in CMS development requests, particularly in the area of CMS requesting that the submitter essentially “prove” that all claim related records for the most recent 2 years of treatment, regardless of who paid for the treatment, were submitted in entirety to CMS along with the proposed MSA allocation. The critical initial phase of the MSA review process is conducted for CMS by the Workers’ Compensation Review Contractor (WCRC). The WCRC is a specialized contractor hired by CMS to review and evaluate WCMSA proposals. If the WCRC identifies missing or insufficient information during its review, it will issue a development request to the submitter. This request asks for additional documentation or clarification to complete the review. The following is an excerpt from one such development request, and is similar or identical to development requests received in multiple jurisdictions by multiple MSA submitters across the county. It appears that this language is “boilerplate” and sent regardless of the case specifics. “Send updated medical records for all major surgeries/procedures and the most recent two years of treatment records related to the industrial injury from all treating physicians, even if the carrier has not paid for the treatment. Medical records for the most recent two years of treatment related to the industrial injuries/conditions are needed, which may not be within the last two calendar years.” “If the industrial injury occurred less than two years ago, send all medical records from the date of injury through the date of submission. AME/IME/Med-legal reports are not a substitute for treating physician records. If the claimant has not been treated by a doctor for any reason within the last two calendar years, send a statement from the treating physician(s) indicating when the most recent two years of treatment related to the industrial injury occurred along with the medical records from those most recent two years of treatment.” “A statement indicating the claimant has not been treated in the last two years is not a substitute for medical records for the most recent two years of treatment. Include all medical records related to the industrial injury for the most recent two years prior to the last treatment date.” These development requests are being sent on cases where the submitter confirmed for CMS that all claim related treatment records with the most recent 2 years of treatment were in fact, submitted with the initial proposal. The submitter will typically be told the information must be submitted within 10-20 days of the request or the case will be closed. The good news is the case is easily reopened when the information is received. However, the time and expense incurred in researching and responding to these requests can be significant. In addition, these requests for ‘current’ medical records, pharmacy history, and/or an updated carrier payout becomes a vicious cycle in cases where the patient continues to treat, and can result in a repeated development requests. We’ve watched cases being closed and re-opened multiple times, causing the CMS review process to extend far beyond 6-8 weeks. From the WCRC perspective, a closure due to missing information places the burden back on the submitter and the case is technically complete; the WCRC has done their job. The result of this recent increase in development requests is that claims are taking longer to settle or not settling at all based on lack of CMS approval. All parties become frustrated by the delays. If settlement is pursued, parties may consider language making closure contingent on CMS acceptance, or the settlement may cover indemnity only, leaving medical open. Of course an alternative option is to move forward without CMS approval of an MSA, essentially using the MSA allocation as a “nonsubmit” MSA and this is certainly a trend we are seeing. When relying on the carrier MSA proposal without CMS approval, it is important to have an accurate understanding of future medical needs based on CMS submission guidelines. In reality, many cases will not even meet CMS review thresholds, yet all settlements must consider Medicare’s interests. Regardless of the reason for non-submission, it is important to have an accurate understanding of the future medical exposure in all cases involving future medical settlements. This allows you to optimize your position during settlement negotiations. Let MSS assist you in navigating MSA reviews and nonSubmit MSA situations! Do you have additional questions about MSAs, how to value future medical care or posturing your cases for future medical settlement? Contact us for more information! Schedule time to discuss how MSS can assist you identify and value your client’s future medical care needs! Click here for more information. Stay tuned for Part I of our MSA reporting Series – What Are the New Medicare Reporting Rules! |
| Our step-by-step process to get MSS working for you couldn’t be EASIER: Use our client portal at medicalsettlementspecialists.com to complete a case intake form and upload documents. On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement, review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.) Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you! |