Last week, ECS hosted another highly engaging national webinar, “WCMSA Reporting: One Year Later.” The session generated record-setting audience participation and an exceptional volume of questions, underscoring the industry’s continued focus on the evolving CMS requirements. With the recent updates to the NGHP User Guide and aCMS Town Hall call addressing WCMSA reporting, the timing could not have been better.
Given the overwhelming response, we felt it was important to continue the conversation by answering some of the most frequent questions submitted during our webinar.
Questions about new ORM Termination guidance
Much of the discussion centered around CMS’ updated ORM Termination guidance, which clarifies that an RRE’s refusal to accept ORM “is a valid ORM termination reason” if “that refusal is permitted by applicable state or federal law and the terms of the insurance contract.” This amendment arguably allows RREs to avoid a number of absurdities that were present in ORM reporting – for instance on older closed claims that RREs may have been reluctant to terminate because the claim fell outside of CMS’ relatively restrictive official guidance. Below, we break down some of the many questions we received on this topic.
Q. Under this new guidance would we be able to terminate ORM based on a favorable IME?
A. Ongoing responsibility for medical is something that should be reported whenever a claims payer has “currently assumed” the responsibility to reimburse providers for related medical care. An ORM termination date should be reported whenever “ORM ends” – meaning whenever the responsible reporting entity is no longer paying for related medical care. To answer the question more specifically, if the favorable IME means that the claims payer will now deny the claim entirely then an ORM termination can be reported. But if the IME only impacts the nature and extent of the injury, as opposed to the relatedness of the injury, then a more appropriate response may be to update the appropriate ICD-10 code. The new guidance does not change any of this analysis – you could always report ORM termination whenever a claim was controverted following investigation.
Q. If there was no treatment for several years, but there’s no statute of limitations in a state and we’ve long closed the claim, can we now report ORM termination?
A. The new guidance from CMS an RRE may report ORM termination whenever responsibility for medical “has been terminated [for] any reason … not prohibited under the terms of the insurance contract or the applicable state or federal law.” It further states that an RREs decision to terminate ORM is valid provided that the determination to “refuse” to continue to accept ORM is “permitted by applicable state or federal law and the terms of the insurance contract.” So, where there’s been no treatment for several years, the case is closed, and the law or terms of the contract would allow the RRE to say that it’s no longer responsible for medical, ORM termination can be reported. This is even in situations lacking recent medical records; where the RRE may have paid more than $25,000 medical; where there are no statutes of limitations, etc. The key as always is responsibility and the key question to ask is: are you (still) responsible for that person’s medical care? If you terminate ORM and are later presented with medical that cause you to reopen the claim and pay medical, simply remove the ORM termination date and file an update record.
Questions about WCMSA reporting
Naturally, we also received numerous questions regarding CMS’ recent Town Hall webinar on WCMSA reporting. You may recall that in its guidance, CMS indicated that while still optional, not providing data such as the case control number or CCN (the serial number provided whenever an MSA proposal is submitted for review) and the professional administrator EIN could create unintended challenges once the claim is reported. CMS also confirmed that submitting a TPOC report prior to completion of WCMSA review would mean that the WCRC would “take no further action with the submission” of the case.
Q. What happens if we report a case control number that doesn’t match an existing case control number in CMS’ system?
A. We’ve learned that when a case control number can’t be matched to an existing case control number, CMS’ logic will return a “hard error” and will prevent the entire claim record from being successfully reported. This increases the risk that an RRE will receive a civil money penalty due to delayed transmission of TPOC data. As we mentioned during the webinar, we believe this is an extremely unfortunate and short-sighted determination by the agency. The only field in the entire Section 111 reporting record layout that lives only in the CMS system is case control number – so penalizing RREs for not getting this number correct is troubling. We hope that this was a mere oversight and that CMS quickly updates its logic.
Q. You mentioned that we can file update records to ensure that CMS receives accurate WCMSA data. Will that impact any “stuck” MSAs?
A. No. An update record will not impact the review of any MSA submitted to CMS for review and approval. We are seeing progress towards moving the review of these cases to completed statuses, but as far as impacting the actual review of the case the answer is no. We want to emphasize that this is a relatively small number of cases but if it’s your case of course that’s the only case you care about. To prevent review from being held up we recommend that you simply hold off on TPOC reporting until such time as the case actually settles in all respects (including the MSA).
Other Miscellaneous Questions
Q. Does CMS’ updated wrongful death guidance mean we have to report wrongful death claims after all?
A. CMS updated their guidance to focus on reducing or eliminating conditional payments in a wrongful death settlement. The key guidance is that “the critical variable to consider is whether or not a settlement releases or has the effect of releasing medicals. If it does, regardless of the allocation (or lack thereof), the settlement must be reported.” Our guidance in handling a wrongful death claim is to focus on answering that question – are we releasing a claim for medicals? If the answer is yes, then the settlement is reportable. If the answer is no, then it’s not reportable. State law can vary on this topic and if you have any questions about how it can apply in your settlement please contact the ECS compliance team at mspcompliance@examworkscompliance.com.
Q. How will we report all ICD codes on the earliest claim if that claim was never reported due to denial?
A. In its recent User Guide updates CMS has asked RREs to report the TPOC on the earliest released date of incident, and to simply terminate ORM (if applicable) on any subsequent DOI that’s part of that one global settlement. The short answer is yes, you should apply everything on the first DOI if possible. The caveat is that we’d be hard pressed to recommend that RREs explore making changes that would violate normal claims-handling protocols. For instance, if there is an incident only claim that was never filed that gets added to the settlement release paperwork at the last minute as the earliest DOI – leave that on the cutting room floor. Start with he earliest date of incident that you are aware of and intend to resolve in the global settlement.
As you can see, there was a lot to discuss! To view the full webinar, click here. If you have any questions, do not hesitate to reach out to the ECS Compliance Team at mspcompliance@examworkscompliance.com.
