When dealing with Workers’ Compensation Medicare Set-Asides (WCMSAs), one critical phase that often determines the outcome is the review process conducted by the Workers’ Compensation Review Contractor (WCRC). The WCRC plays a pivotal role in ensuring that Medicare’s interests are protected by thoroughly evaluating the adequacy of proposed WCMSA amounts. This blog post will explain the WCRC review process, shedding light on its importance and the steps involved.
What is the WCRC?
The Workers’ Compensation Review Contractor (WCRC) is a specialized contractor assigned by the Centers for Medicare & Medicaid Services (CMS) to review and evaluate WCMSA proposals. The WCRC’s primary responsibility is to ensure that the funds allocated in a WCMSA are sufficient to cover the claimant’s future medical expenses related to the work injury, thereby protecting Medicare’s interests.
The Importance of the WCRC Review
Submitting a WCMSA for CMS review and approval is not a legal requirement, but it is highly recommended in cases where Medicare’s interests must be considered. By having the WCRC review the proposed set-aside amount, the parties involved gain assurance that Medicare will not seek recovery for medical expenses related to the injury once the set-aside funds are exhausted. Without WCRC approval, Medicare could refuse to pay for future medical expenses related to the injury or demand repayment from the settlement.
Steps in the WCRC Review Process
The WCRC review process involves several key steps, each designed to thoroughly assess the proposed WCMSA and ensure that it meets CMS guidelines.
- Receipt and Initial Review:
- Once a WCMSA proposal is submitted, either electronically via the WCMSA Portal or through a paper/CD submission, it first goes through an initial review to ensure all required documentation is present. The WCRC verifies that the submission is complete and that it includes essential information such as medical records, payment histories, and the proposed set-aside amount.
- Validation of Information:
- The WCRC begins by validating the claimant’s demographic information, including the claimant’s name, Medicare ID, Social Security number, and other identifying details. The WCRC also checks the contact information for all relevant parties, such as the claimant’s attorney and the WCMSA administrator.
- Jurisdiction and Calculation Method:
- The WCRC verifies the jurisdiction for the claim, which affects the pricing and calculation method used for the WCMSA. The pricing is based on the state’s workers’ compensation fee schedule or, in some cases, actual charges if no fee schedule exists. The WCRC ensures that the correct jurisdiction and corresponding pricing methodology are applied.
- Medical and Pharmacy Review:
- The WCRC performs a detailed review of the claimant’s medical records to determine the future medical care needs related to the injury. This review includes evaluating the claimant’s medical history, current treatment, and any anticipated future treatments. The WCRC also reviews pharmacy records to assess ongoing and future prescription drug needs.
- During this step, the WCRC utilizes evidence-based guidelines, medical literature, and clinical expertise to determine the adequacy of the proposed set-aside amount. The review considers factors such as the claimant’s life expectancy, the severity of the injury, and the expected duration of treatment.
- Evaluation of the Proposed Set-Aside Amount:
- The WCRC compares the proposed WCMSA amount with its own calculations to determine if the amount is sufficient to cover the claimant’s future medical expenses. If the WCRC finds that the proposed amount is inadequate, it may recommend a higher set-aside amount. Conversely, if the proposed amount is deemed sufficient, the WCRC will recommend approval.
- Development Requests:
- If the WCRC identifies missing or insufficient information during its review, it will issue a development request to the submitter. This request asks for additional documentation or clarification to complete the review. The submitter must respond to these requests within a specified time frame, typically 20 business days for electronic submissions.
- Final Determination:
- Once the WCRC has completed its review and all necessary information is received, it makes a final determination. The WCRC’s recommendation is forwarded to CMS, which then issues an official approval or counterproposal based on the WCRC’s findings.
- Notification of Decision:
- After CMS makes its final determination, the parties involved are notified of the decision. If the WCMSA is approved, the settlement can proceed, and the funds can be set aside as proposed. If the WCRC recommended a higher set-aside amount, the parties may need to adjust the settlement accordingly.
Conclusion
The WCRC review process is a critical step in the establishment of a WCMSA, ensuring that the proposed amount is sufficient to protect Medicare’s interests. By thoroughly evaluating medical and pharmacy records, validating jurisdiction, and applying evidence-based guidelines, the WCRC plays a vital role in safeguarding both the claimant’s and Medicare’s future financial responsibilities.
For claimants, attorneys, and insurers, understanding the WCRC review process is essential to successfully navigating the complexities of WCMSAs. Submitting a well-documented and accurately calculated WCMSA proposal can streamline the review process and help avoid delays, ensuring a smooth path to settlement approval.
If you have questions about the WCRC review process or need assistance with a WCMSA submission, our team at Yrulegui & Roberts is here to help. We specialize in workers’ compensation cases and are committed to protecting your rights and ensuring compliance with Medicare guidelines.
