CMS Selects a New Contractor to Review Workers’ Compensation Medicare Set-Aside Proposals

The Centers for Medicare and Medicaid Services (CMS) awarded a new Workers’ Compensation Review Contractor (WCRC) contract last week to Provider Resources, Inc. of Erie, Pennsylvania.   This new contract is encouraging news to the Medicare Set-Aside and claims settlement industries because the WCRC is the sole nationwide reviewer of Workers’ Compensation Medicare Set-Aside (WCMSA) proposals for CMS, and recent delays in this process have been hampering settlements all over the country.

Provider Resources, Inc. (PRI) is headed up by Ms. Shawn Keough-Hartz, CEO and President, a 22-year veteran of the healthcare industry with extensive experience in coding, billing, compliance, IT systems and government contracting.   Dr. Dennis Agostini, PRI’s Medical Director, has a resume that is equally impressive with advanced degrees in chemistry and osteopathic medicine, and over 30 years of experience in directing organizations’ medical policies and programs.   Dr. Agostini also served our country as a Major in the US Reserves, Medical Corps during Operation: Desert Storm.   PRI has experience working with CMS as a Recovery Validation Contractor in CMS’s Recovery Audit Contractors Program.  PRI will be working with a currently unnamed subcontractor in Richmond, VA.

The $5,124,084.00 contract is for one year, starting on July 1, 2011 and ending June 30, 2012, which includes a 3-month transition period and a 9-month base production period.  After the first year, there are four separate 12-month option periods, which can be exercised at the discretion of the government.

The contract requires that all WCMSA proposals be reviewed within 20 business days of receipt, and anticipates a volume of 2,000-2,500 WCMSA proposals per month.  “High-priority” cases for severe claimant financial hardship, catastrophic health problems, or those with “congressional interest” must be reviewed within 2 business days.  Specific contract provisions require PRI to notify the submitter within 5 days if there is any missing information, and then complete the review within 15 days from the receipt of that missing information.

Education and outreach activities are an integral part of the contract.  PRI is required to “continuously” and “proactively” educate employers, insurers, attorneys, providers, suppliers and beneficiaries by use of seminars, workshops, presentations, conferences, webinars and print material.

Additionally, the contract requires that the WCRC staff include a physician, a pharmacist, pharmacy technicians, and an attorney; something that the MSA industry has been requesting for years.

Can Provider Resources, Inc. meet these rigorous contract requirements?  I’m not sure, because I’m battle wearied from the current 90-120 day turnaround times.  But, I’m optimistic.  PRI appears to have the qualifications and experience, and just the letting of this stringent contract shows that CMS is serious about trying to fix the current problems.

WCRC contract detail can be found here.

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