We recently blogged that CMS delayed the Workers’ Compensation Review Contractor (the entity that reviews Workers’ Compensation Medicare Set-Asides) award to the 2ndquarter of 2017, with the solicitation being released in the 1st quarter. For our prior blog, click here.

CMS has now released their draft Request for Proposal (RFP) as well as draft Statement of Work (SOW) for the Contractor.  While it is draft and not final, it sheds some light into changes that may come with a new Contractor award. To view the draft RFP and SOW, click here.

Specifically, the SOW contains specific language about how the contractor would review “other” non-group health plan set-asides. The review of Liability Medicare Set-Asides (LMSAs), if adopted, would be broken down into two categories: a full review and a cursory review, based on settlement amounts.  Full review cases would be subject to a similar review process as currently implemented for WCMSA submissions, while a cursory review would only require that all required documents were provided for an amount determination to be made (see section C3.2.2 of the SOW). CMS estimates that as much as 11,000 or as little as 800 cases would require a full review, based upon industry response. Additionally, CMS estimates there would be potentially 40,000 cases that would require a cursory review.  Clearly, CMS is maintaining its intent for the new contractor to begin a voluntary review of LMSAs and is setting out two (2) different methodologies in which it would do so, and liability primary payers should watch this closely.

With regard to WCMSAs, the SOW states that the contractor should anticipate receiving 1,600 new WCMSA proposals per month, which would represent 42% of its workload. The rest of its workload would involve previously submitted WCMSAs that are at various stages of review/completion. Lastly, 10% of its workload would involve re-review requests. The contractor will have a 20-day time-frame to review MSA submissions; this is a positive requirement in the RFP in that it would continue current fast turnaround times with the current WCRC.

The RFP provides that comments on the proposed RFP are being requested and that all comments will be taken under consideration for possible revisions to the Draft RFP. Interested parties are asked to submit written comments to Stephen.Stoyer@cms.hhs.gov by 11:00 AM Local Prevailing Time (LPT) on December 7, 2016. We encourage stakeholders to submit comments to CMS on this draft RFP.

Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP

Chief Legal Officer


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