Workers’ Compensation Review Contractor Protest

December 14, 2017

In September of this year the Centers for Medicare & Medicaid Services (CMS) announced the award of a new Workers’ Compensation Review Contractor (WCRC) contract to Capitol Bridge, LLC. That award was protested by two organizations – KEN Consulting and Arch Systems – the latter of which could have resulted in review by the existing contractor. The Government Accountability Office (GAO), which reviewed the protests, rejected the protests on Tuesday, December 12th. The protest decisions have not been published, but we anticipate they will be posted soon.

Consider recent WCRC contract performance.

The WCRC reviews Medicare Set Asides submitted for review and approval.  It plays an important role in either facilitating or delaying workers’ compensation settlements involving Medicare beneficiaries.  Medicare Set Aside review requires the contractor to review medical records and payment histories, apply often nebulous guidance from CMS, and work directly with submitters to address questions as they arise.  Swift and relatively reasonable reviews, may be taken for granted by practitioners in 2017, but a few short years ago, under the prior contractor, the wait times were far longer and the reviews were far less reasonable.

After some initial hiccups that occur during contracting transitions (particularly related to a troublesome affinity, roughly four years ago, to delay response on perfectly good submissions), the incumbent WCRC contractor, Provider Resources, Inc. (PRI), has done an admirable job of reducing review times, increasing transparency, and improved service.  Simply put, Provider Resources has proven a tremendous upgrade over the last three years versus the prior contractor. 

It is therefore puzzling that CMS has placed its bets on a new horse, Capitol Bridge, LLC.  Medicare contractor transitions rarely go smoothly.  Issues that everyone thinks are nailed down are inevitably overlooked.  Inexperienced individuals must be trained.  The review program needs to take shape and find its legs. 

While Provider Resources reviewed cases with aplomb, Capitol Bridge, LLC is an unknown.  We do know that Maximus, a massive Federal contractor, has been advertising for individuals interested in joining their organization as Medicare Set Aside reviewers, working on behalf of CMS.  It may be that Maximus is subcontracting with Capitol Bridge to perform these assessments.  We will have to wait to see how this partnership shakes out.

Look at the details of the contract.

As we mentioned in September, the new WCRC contract is for more than $60 million.  The request for proposal published by CMS outlined that the winning bidder will need to be capable of reviewing liability Medicare Set Asides.  CMS has yet to announce any policy initiatives surrounding LMSAs, although in a tersely worded October 2017 statement it explained that it “continues to consider expanding” the voluntary review process and that it “will work closely with the stakeholder community to identify how best to implement this potential expansion of voluntary MSA reviews.”  CMS has talked quite a bit about LMSAs over the last six years.  Apart from some back-end changes to the common working file, little has taken shape in the form of a substantive policy.  At some point, it is possible that the new contractor will be faced not only with reviewing workers’ compensation MSAs, but also liability MSAs in the event that CMS puts close to six years of words into action.

What do practitioners need to know?

At the end of the day, the WCRC plays an incredibly important role in facilitating prompt review of MSAs and settlements.  MSA review is not mandatory, but depending upon the circumstances of each case and the risk management goals of claims payers, attorneys, and workers’ compensation judges, it is often a necessary evil.  We know that Provider Resources is incredibly efficient in its reviews, even if we can disagree with the outcomes from time-to-time.  Right now, with the current contractor, we have relative certainty in terms of turnaround times and results on cases that we submit. 

We simply do not know what it will look like with a new contractor. Critically, we still do not even have a formal timeline for a transition to a new contractor.  At this point, it appears that the existing contractor will be reviewing cases through at least the end of Q1 2018.

Federal contracting is an often byzantine process with many fits, starts, twists, and turns.  Merely having a bid protest rejected by an initial GAO review is not the end of the road.  It’s possible that the program remains largely unchanged for several more months as protests continue and move forward beyond this initial stage or some other remedy is explored, including a complete recompete for the RFP.  Every day with PRI at the helm provides relative certainty for parties seeking CMS approval. 

What are the next steps for practitioners?

ExamWorks Compliance Solutions is the most experienced provider of Medicare Set Aside services in the industry, and is closely following this contractor transition.  Our team of experienced nurses, pharmacists, and attorneys have been through every prior Medicare contractor transition both in MSAs and conditional payments.  We are here to provide strategies to offset any issues that may develop in any contractor transition.   Please contact Marty Cassavoy, Vice President of MSP Compliance, at 781-517-8085 or with any questions about this contracting process, the transition, and what it may mean to your organization. 

Marty Cassavoy

Marty Cassavoy

Marty Cassavoy is the Vice President of MSP Compliance at ExamWorks Compliance Solutions. Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer compliance and across all insurance types. An attorney licensed to practice law in Massachusetts, Marty works out of ExamWorks’ Woburn, Massachusetts office and can be reached at 781-517-8085 or