Zero WCMSA submissions are getting mired in a cycle of CMS development letters and responses, as the CMS Workers’ Compensation Review Contractor (WCRC) becomes increasingly meticulous about formatting requirements for submitted pay histories. Many of the current WCRC reviewer requests are not even listed requirements in either the WCMSA reference guide or the CMS operating rules.
The WCRC is being recalcitrant
The majority of insurer claim systems can’t provide the requested information in the WCRC’s preferred format, and the WCRC reviewers are requiring carriers to respond to development letters with painstaking exactness. Compounding the problem: the WCRC isn’t accepting reasonable alternative documentation or information.
Three common CMS requests—and ways to respond
Request: The WCRC reviewer wants specific information about reserves, citing section 10.8 of the WCMSA reference guide as support.
Rule: A request for reserves is not required by either the WCMSA reference guide or the CMS operating rules. So, the language in section 10.8 of the WCMSA reference guide does not support the reviewer’s request. Section 10.8 in fact requires an acknowledgment that reserves were not set up if there is no medical history printout available:
“A letter from the carrier or its attorney explaining why there is no printable history if the carrier made no payments of medical, indemnity, or expenses, and did not even set up settlement reserves for the claim.”
Recommendation: Indicate that request for reserve information is in error and that a carrier letter regarding reserve information per section 10.8 is only applicable when a printable pay history cannot be provided. As part of the development response, provide a copy of the pay histories, outlining why the pay history information conforms to requirements (subtotals, grand totals, dates, etc.). If the pay history is in order, the reviewer should no longer inquire about the reserve issue.
Request: In one complete document, present the medical pay history with separate categories, subtotals, and a grand total—and include a carrier signature.
Rule: None of these requests are stated as a requirement in either the WCMSA reference guide or the CMS operating rules.
Recommendation: Comply by being completely thorough. Make sure the claim pay history has the claimant’s name, the date of injury, the insurer’s name, a full date range of the claim, page numbers, print date, subtotals, and grand total, with separate medical, indemnity, expenses, and expenses. Have the history signed with a statement that it is “a complete representation of all payments made on the claim.” If some of the information is missing, handwrite it on each page with the adjuster’s signature. A signed carrier letter explaining any handwritten inclusions may help support the pay histories.
Request: Include a hand-signed letter of explanation (on letterhead) from the insurer or insurer’s attorney, stating why there is no printable history if the insurer made no payments for medical or indemnity and did not even set up settlement reserves for the claim—along with a signed copy of the available pay record noting that “it is a complete representation of all payments made on the claim (including medical of $0 and indemnity $0).”
Rule: Per the WCMSA reference guide, listed under section 10.8, the WCRC should accept an insurer letter of explanation in lieu of providing the pay history if a printable pay history cannot be provided.
Recommendation: If the WCRC reviewer also requests a signed copy of the available pay history, we recommend pushing back. The explanation in the insurer’s letter should be sufficient pursuant to section 10.8, and the carrier is providing the explanation letter because it can’t provide a printable pay history.
CMS should loosen the pay history format requirement
We’re concerned that CMS has been requesting information that does not appear to be required for the zero MSA process—and only accepts exact responses to those requests. The recent restrictions imposed by a stricter zero MSA development process have the effect of reducing the number of zero WCMSA approvals.
Previously, in October 2016, CMS attempted to implement an unannounced policy change to the zero WCMSA process that would eliminate zero MSA approvals. Fortunately, the October re-review change was later rolled back.
ISO Claims Partners will continue to develop applicable responses to the zero WCMSA development letters and advocate for CMS to reverse a frustrating trend.