What's Hot, What's New

WHAT'S NEW, WHAT'S HOT, WHAT'S RUMOR IN PA WORKERS' COMPENSATION

The revised Utilization Review Form is now being accepted by the PA Bureau of Workers Compensation as of 10/24/2011. The new form will be required as of 1/2/2012.

What does the new form offer? It allows you to list up to 5 providers on one form. In practices where multiple providers of the same specialty can treat the same patient such as physical therapy or chiropractic treatment, this will allow one review of multiple providers, vs. having to file a Utilization Review for each provider. If one reviewer is assigned then there will be consistency in the review determination vs. before where mutliple reviewers were assigned to the mutliple providers. This should also help to reduce the cost of the Utilization Review where there is one specialty.

Also new to the form is a section to include the WCJ Circulation Date. If payment for the treatment was withheld because treatment was under review, the date of the decision will show the reason for the delay and define the time frame the request can be made.

You can find the new form at the PA Bureau website at http://www.portal.state.pa.us/portal/server.pt?open=514&objID=552595&mode=2

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Just in! The latest edition of the NGHPR User Guide, Version 3.2 is now available on CMS' website. Here is the link to obtain your copy of the manual: http://www.cms.gov/MandatoryInsRep/Downloads/NGHPUserGuideV3.2.pdf

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It's time! Section 111 reporting has been in place for over a year , identifying workers' compensation and liability claimants where Medicare has made conditional payments on behalf of the primary payer. Now, CMS is beginning to recoup that money and is preparing to start collecting on those payments.

CMS has contracted with Medicare Secondary Payer Recovery Contractor, or MSPRC for short, who is now responsible for systematically identifying and collecting conditional payments from primary payers in cases where claims were not denied by workers' compensation.

So how is MSPRC going about collecting on these payments? First, they send out what is called a "Conditional Payment Letter", which is a record of all payments that they believe they have made on behalf of the claimant. Once received, the ball is in your court. It is your job to review the letter and determine whether or not all of the payments they have included are related to your work-related injury. This is important because you are responsible for payments to work-related injuries, but not for the non work-related injuries. If you find that you are not responsible for one or more payments, it is up to you to collect the medical records to prove the treatment was not related to the work injury and submit these to MSPRC. Once the payment amount is agreed upon, MSPRC will send out a "Demand Letter", which can be thought of as your bill. Once you receive this demand letter, you have 60 days to make your payment. If you do not make payment within the 60 days, MSPRC will send the letter to the Federal Treasury Department who will oversee the collection from that point forward. Note, interest is assessed beginning the 61st day of the nonpayment period. Of course this is a very simplified rendition of the process. MSPRC has numerous letters that may be sent. The moral of the story is that as soon as you get these notices, act quickly!

Although this entire process is brand new, we at ACS Claim Service, Inc. have prepared ourselves for this change by having developed standard letters for the process to help us move quickly through it, by educating our staff to keep them up to date on the change, by implementing monitoring systems to channel the letters to our new MSPRC department, and by having already submitting signed Consent to Release forms to CMS so we are kept up to date on notices being sent to the claimant thus expediting the response process.

More information on the MSPRC and copies of their letters can be found on their website: http://www.msprc.info/