Good news/Bad news

In its continued efforts to reduce the amount of conditional payments expended annually on cases in which Medicare is secondary to Workers' Compensation,  Medicare is set to implement a new MSP code next Monday,  July 6th.  This code will be used in Medicare's claims processing system to specifically identify cases on which the Centers for Medicare and Medicaid Services (CMS) have reviewed a Workers' Compensation Medicare Set-Aside (WCMSA) arrangement.  With the advent of this new code, CMS will now have the capability to deny payments that are related to the diagnosis(es) coded in any given WCMSA arrangement.  All physicians, providers, and suppliers who bill Medicare contractors (including carriers, DME contractors, regional home health intermediaries, and Part A/B Medicare administrative contractors) will be subject to this new coding procedure.  As such, proper coding of the diagnosis(es) in every WCMSA arrangement submitted to CMS is now even more critical.  There is no discussion within this new implementation process regarding application of this new MSP code to MSA arrangements on liability or no-fault cases.

The good news for Workers' Compensation insurance professionals is this:   there should begin to be a decrease in the amount of conditional payments made on your Workers' Compensation claims.   On the other hand, the bad news for Medicare beneficiaries is that they will need to be even more vigilant in administering their WCMSA accounts post-settlement.  Medicare will be sending notices of denial directly to beneficiaries for claims received that appear to be related to WCMSA diagnosis(es) advising them that "Your claim has been denied by Medicare because you may have funds set aside from your settlement to pay for your future medical expenses and prescription drug treatment related to your injury(ies)."

One additional point to ponder….How will this new MSP coding procedure, which will identify cases on which CMS has reviewed a WCMSA,  intersect with the Mandatory Insurer Reporting requirements which will identify for Medicare all Medicare beneficiaries who have received a settlement, judgment, or award?  The days of evading or avoiding MSP issues are quickly coming to an end!

For more information, please see www.cms.hhs.gov/MLNMattersArticles/downloads/MM5371.pdf

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