Highlights from the NAMSAP 2020 Conference

1. Portals are the future

2020 brought great improvements with: 

MSP Recovery Portal (MSPRP)

Open Debt report, Pre Conditional Payment Notice (CPN) worksheet, hover feature in the portal, electronic access to CMS letters, additional information to case detail screen (i.e., if referred to treasury).

Workers’ Compensation Medicare Set-Aide Portal (WCMSAP)

Zip code lookup to identify the appropriate major medical center and the electronic attestation.

Enhancements will continue to be a focus, with the following  potentially on the horizon:

Section 111 Mandatory Insurer Reporting Portal

Responsible Reporting Entities (RREs) will be able to make changes to their address through this portal and not have to make an update through the Tax Identification Number (TIN) file.

Ability to terminate ongoing responsibility for medicals (ORM) real-time in portal so RREs do not have to wait until the next reporting period. This functionality is available today via telephone calls to the Coordination of Benefits Contractor (COBC). CMS expressed concern with this enhancement is that the Section 111 file would also need to be updated or the next file load will revert ORM back to the previous status.

MSPRP

Process to opt-out of paper letters for conditional payments and receive email notifications advising them to go to the portal to pull the notice.

WCMSAP

Electronic attestation - updates for reporting pharmacy spend.

2. CMS does not recognize Non-Submit Workers’ Compensation Medicare-Set-Asides (WCMSAs)

CMS’ position is that a WCMSA is an agreement between CMS and their beneficiary regarding future settlement funds needed for Medicare-covered medical expenses. By circumventing this process the claimant is put at risk. First, Medicare can deny payment for medical treatment needed by the claimant and potentially require that the total settlement amount is exhausted. Second, Medicare could make payment and seek recovery post-settlement up to the total settlement amount. Both of which have administrative appeal rights. Look for an upcoming blog from Optum regarding this topic.

3. CMS is listening to stakeholder feedback

Section 111:

CMS is reviewing how to report partially settled claims (i.e., a settlement occurs for a right knee injury but the low back injury remains open) through Section 111, as there is no option currently to terminate responsibility for one ICD code/body part while keeping the others open. This has been an ongoing concern as the Commercial Repayment Center (CRC) relies on Section 111 data when reviewing conditional payment disputes.  The proposed rulemaking for Section 111 penalties will add additional risk to the RRE for reporting contradicting information to CMS vendors.

CMS is considering a reporting enhancement that will allow an ORM termination date to be set for much later than the six months currently available.

CMS will address the concern raised by  RREs regarding states with lifetime medical benefits, specifically around whether the RRE needs to continue to query the claim until the claimant is a Medicare beneficiary in order to comply with reporting requirements as some claimants may not be a Medicare beneficiary for many, many years. 

Conditional payments:

CMS knows that carriers/Third Party Administrators (TPAs) want to maintain control of the conditional payment recovery process and not transfer it to the beneficiary post-settlement. CMS is considering leaving workers’ compensation cases with the CRC regardless of settlement or accepted/denied status of the claim so the carrier will remain the primary debtor and be able to dispute conditional payments post-settlement.

WCMSAs:

In January 2021, CMS plans to start sending follow-ups letters to payers on cases where WCMSA cases have not been closed in the common working file (i.e., the WCMSA is submitted and there is no closure to the case because CMS is not advised whether or not the case settled or if the MSA was funded). CMS advised that this would impact approximately 115,000 cases.