Workers’ Compensation Medicare Set-Aside User Guide

The Centers for Medicare & Medicaid Services (CMS) updated its Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) User Guide to version 2.2 to reflect some important changes in the WCMSA program.

The following sections of the guide were added or changed:

4.1.4 Hearing on the Merits of the Case.  This section was added to incorporate previous guidance published in the April 22, 2003 WCMSA RO Memorandum, Question 5, that deals with the issue of when CMS will accept a settlement when a state WC judge approves the WC settlement after a hearing on the merits.

9.4.4 Medical Review, Step 8.   Changes were made in this section to clarify the submission requirements for medical and payment records to reflect that if the records for denied cases reflect a payment, medical records may be required to complete the review process. Pharmacy Guidelines and Conditions.  This section was revised to remove reference to drug tables for physician dispensed drugs and consolidate the drug tapering and drug weaning sections of the previous version.

10.5.2 Use of  WC Fee Schedule vs. Actual Charges for WCMSA. Wisconsin was added to the list of states with no workers’ compensation fee schedule.

10.7 Medical Records.   This section was revised to remove the two-year requirement of medical records for treatment unrelated to the work injury.  It also clarified the statements required by the treating physicians.

10.8 Payment History.  This section was revised to say that the entire payment history must be submitted if the proposal asserts a denial of any condition.

Appendix 6 – List of previous version changes.  This appendix was added to document the changes from the previous version of the guide.

It seems that many of these changes were to address the issues of the recent increase in development letters and requests for additional medical records.  This is another welcome addition to the reference material provided by CMS.  It is nice to see that CMS is working with the MSP compliance industry to address issues, resolve problems, and provide published guidance as issues arise.


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