Rafael Gonzalez No Comments

Rafael Gonzalez, Esq. President, Flagship Services Group

It has been a long time coming, two years to be exact. After the Centers for Medicare and Medicaid Services (CMS) announced their anticipated release of a solicitation for the Workers’ Compensation Review Contractor (WCRC) in 2016 and 2017 and further announced it was continuing to consider expanding its voluntary MSA review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts in 2016 and 2017, Medicare Secondary Payer (MSP) stakeholders never thought the day would come. But, after a challenge of the awarded contract and after several months during which Provider Resources continued to work under an expired contract, on March 7, 2018, CMS finally held the WCRC Transition Webinar to introduce Capitol Bridge, LLC, the new workers’ compensation review contractor.

 

A Timeline

On February 22, 2016, CMS announced their anticipated “release of a solicitation for the WCRC.” The anticipated proposal due date was to be April 8, 2016 with an anticipated award date of June 20, 2016.

On April 15, 2016, CMS announced that it was adjusting the solicitation for the WCRC due to “updates to the Statement of Work (SOW) to include the processing of other Non-Group Health Plan (NGHP) Medicare Set-aside Arrangements.” CMS indicated it anticipated releasing the solicitation for the WCRC on or about June 27, 2016, with a due date of July 27, 2016, and an anticipated award date of November 7, 2016.

On June 8, 2016, CMS published an announcement on its website indicating that it would be “considering the expansion of its voluntary Medicare Set-Aside Arrangements (MSA) amount review process to include the review of proposed liability insurance (including self-insurance) and no-fault insurance amounts.”

On September 6, 2016, CMS again amended its anticipated release date for the solicitation for the WCRC to September 22, 2016. This latest change indicated that “CMS anticipated the proposal due date to be October 24, 2016, with an anticipated award date of February 8, 2017.”On October 4, 2016, CMS again announced an update to its pre-solicitation notice “anticipating releasing a solicitation for the WCRC during the first quarter of FY 2017, with an anticipated award date in the second quarter of FY 2017.”

On November 23, 2016, CMS released a Draft Request for Proposal for the Workers Compensation Review Contractor and the Solicitation for the WCRC on December 15, 2016. The anticipated proposal due date was January 2017 with an anticipated award date of Third Quarter of FY 2017.

 

The WCRC Contract is Awarded

After several months during which the incumbent contractor, Provider Resources, worked under an expired contract, the new WCRC contract was awarded on September 1, 2017 to Capitol Bridge, LLC of Arlington, Virginia. The contract award amount was listed as $60,759,236, a significant increase from the 2011 contract award to Provider Resources of $5,124,084, probably due to CMS’ expectations of an increase in the volume of MSA submissions, including the review of Liability Medicare Set Asides (LMSAs) and No-Fault Medicare Set Asides (NFMSAs), despite the anticipated and ongoing voluntary nature of the CMS review program.

On October 24, 2017, CMS again announced it was “continuing to consider expanding its voluntary MSA review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts.” After a challenge of the awarded contract to Capitol Bridge, LLC, and after several more months during which Provider Resources continued to work under an expired contract, on March 7, 2018, CMS finally held the WCRC Transition Webinar to introduce Capitol Bridge, LLC, the new workers’ compensation review contractor.

 

CMS Holds Webinar with Capitol Bridge as New WCRC

The webinar did not address any policy questions, but simply addressed transition questions and concerns. While the question of LMSAs arose during the call, LMSAs were not discussed at all, and were not dealt with in any detail. Instead, we were told that the latest user guide will continue to apply; that the process and calculation methodologies of WCMSAs will not change; that the transition is expected to be smooth and seamless as Capitol Bridge has employed nurses, physicians, attorneys and administrative staff that are well versed in the WCMSA submission process; that Capitol Bridge does not expect any backlog since the review of WCMSAs should be completed within 20 days, if no development has been issued; that the WCRC wants and is willing to automate the WCMSA review process as much as possible; and that the portal will not be effected by this transition.

 

WCRC Contact Information as of March 19, 2018

Provider Resources will stop production on 03/16/18, and Capitol Bridge will start on 03/19/18, at which point, the contact information for the WCRC will be as follows:

 Phone: 833.295.3773
 Email: WCRC@capitolbridgellc.com
 Fax 585.425.5390
 Hours: 9am- 5 am EST

As always, we will continue to monitor the WCRC and any ongoing changes, news, or updates. We will continue to report any substantive or procedural changes that the WCRC may communicate or publish. And we will certainly keep you abreast of any news regarding the long awaited anticipated changes pertaining to reviews of LMSAs and NFMSAs.

 

About Rafael Gonzalez

Rafael Gonzalez, Esq. is President of Flagship Services Group. He has over 30 years of experience in the auto, liability, no-fault, and work comp industries. He is one of the country’s top experts on Medicare and Medicaid compliance, serving insurers, self-insureds, and third party administrators. He speaks and writes on mandatory insurer reporting, conditional payment resolution, set aside allocations, and professional administration, as well as the interplay and effect of these processes and systems and the Affordable Care Act throughout the country. Rafael blogs on these topics at Medicare Compliance for P&C Insurers at www.flagshipservicesgroup.com/blog. He is very active on LinkedIn, Twitter, Instagram, and Facebook. He can be reached at rgonzalez@flagshipsgi.com or 813.967.7598.

 

About Medicare Conditional Payments

42 CFR Section 411.21 indicates that Medicare conditional payments are payments made by Medicare for medical treatment where a primary payer (insurer or self-insurer) has or may have an obligation to make such payment. Primary payers must reimburse Medicare for conditional payments it has made. 42 USC Section 1395y indicates that primary payers include group health providers, workers’ compensation, liability and no-fault insurers and self-insured entities, as well as physicians, attorneys, hospitals, or clinics that receive payment from a primary payer must make reimbursement.

42 USC Section 1395y also indicates responsibility as a primary payer arises even if liability for the medical expense is contested. Such a responsibility can be demonstrated by entry of a judgment or by payment conditioned on a release or waiver of payment, even if liability is denied. 42 CFR Section 411.24 indicates Medicare has a direct right of action against all primary payers responsible for making payment. And, Medicare has a direct right of action against any person or entity that received a primary payment, including the Medicare beneficiary, medical provider, physician, attorney, state agency or private insurer.

 

About Medicare Advantage and Prescription Drug Plans Reimbursement

42 CFR Section 422.108(f) provides MAPs with the same rights of recovery that the Secretary of HHS has under the MSP regulations in subparts B through D of part 411 of 42 CFR. Additionally, the same MSP regulations at 42 CFR Section 422.108 are extended to PDPs at 42 CFR Section 423.462. Therefore, PDPs have the same MSP recovery rights as MAPs, which have the same recovery rights as HHS. This includes, as recent federal appellate and district court decisions have indicated, the ability to pursue double damages through MSP private cause of action pursuant to 42 USC Section 1395y(b)(3) should the primary payer deny the MAP or PDP reimbursement of any due conditional payments.

 

About Medicaid Third Party Liability Liens

42 USC Section 1396a mandates that all reasonable measures to ascertain legal liability for Medicaid payments and reimbursement of same be taken. The state or agency administering a Medicaid plan must take all reasonable measures to ascertain the legal liability of third parties to pay for care and services paid by Medicaid. Federal law also provides that in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual, the state or local agency must seek reimbursement for such assistance to the extent of such legal liability. 42 U.S.C. Section 1396a(a)(25).

 

About Flagship Services Group

Flagship Services Group is the premier Medicare and Medicaid compliance services provider to the property & casualty insurance industry. Our focus and expertise has been the Medicare and Medicaid compliance needs of P&C self-insureds, insurance companies, and third party administrators. We specialize in P&C mandatory reporting, conditional payment resolution, and set aside allocations. Whether auto, liability, no-fault, or work comp claims, we have assembled the expertise, experience and resources to deliver unparalleled MSP compliance and cost savings results to the P&C industry. To find out more about Flagship, our folks, and our customized solutions, please visit us at www.flagshipservicesgroup.com. To speak with us about any of our P&C MSP compliance products and services, you may also contact us at 888.444.4125 or info@flagshipsgi.com.

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