The news of Medicare's new TPOC/WCMSA reporting requirement has raised a number of important questions and practical issues which insurers should consider ahead of CMS's April 4, 2025 go-live date. In a nutshell, as outlined in our recent in-depth article, under this new process CMS will require insurers to report several WCMSA data points as part of settlements involving Medicare beneficiaries.

As insurers begin to work through how to address this new requirement (both practically and from a policy perspective), one core factor to consider is that, for the first time ever, CMS will have more of a holistic picture of how insurers consider Medicare's interests in their settlements --- thus, insurers may want to consider asking a couple of key questions as outlined below.

Consideration Points

Key questions to consider upfront are: What will your Section 111 reporting data show CMS regarding settlements involving Medicare beneficiaries when viewed at either the claim level or in aggregate? When CMS reviews your data, how confident are you that they will see inclusion of a WCMSA in the type of claims that you would likely expect a WCMSA to be included? Are you concerned if your data shows no WCMSA has been included?

In the author's experience, when it comes to WCMSAs, many insurers have determined their risk tolerance regarding when to include (and not to include) a WCMSA. The bigger challenge, however, is making sure the front-line claims handler consistently obtains a WCMSA in accordance with the insurer's protocols. Too often there is a divide between protocol and practice, and what often results is inconsistency, which may create potential liability. This oversight is understandable as Medicare is often a small component of the many issues and obligations a claims handler must consider and address.

In the big picture, undoubtedly, having WCMSA protocols in place is an important piece regarding Medicare compliance. Without such protocols, claims handlers may be left on their own to deal with the WCMSA issue, which often times creates a situation where WCMSAs are either obtained when they are not needed, or not obtained when they should be. Even in situations where insurers have specific WCMSA protocols in place, this may still not be enough since, at the end of the day, to be successful, protocols rely on individual awareness of both the issue and established protocols , and even the best trained and best-intentioned individuals make mistakes. This is further compounded by the fact that claims teams have full desks which may distract from the important goal of getting claims to settlement. The good news is that Verisk's MSA Link can help bridge these gaps to help you achieve more consistent WCMSA compliance-related practices as discussed below.

Verisk's MSA Link

The challenges and realities outlined above are exactly why Verisk has launched MSA Link. Like CP Link does for conditional payments, MSA Link uses existing Section 111 data to identify when a claim is ready for an MSA and automates initiation of the appropriate WCMSA service in accordance with your protocols.

By using existing Section111 data, MSA Link:

1. Facilitates, in accordance with your protocols, getting claims properly allocated at the right time.
2. Saves adjuster time and resources by no longer requiring them to submit a referral.
3. Helps prevent delays in settlement so that WCMSAs are obtained when applicable per your protocols.
4. May lower costs by limiting WCMSAs to only those claims that meet your protocols, thereby reducing the number of MSAs that are obtained but never used.

The result? A holistic, broad-ranging, and consistent MSA program that aligns with your risk tolerance, provides CMS with a more accurate view of your WCMSA practices, and facilitates CMS's review of your WCMSA TPOC data. In addition, and importantly, MSA Link helps your claims handling team by taking a key set of tasks off their plates, allowing them to focus more closely instead on getting claims resolved.

Up Next - TPOC/WCMSA and low dollar settlements

In assessing CMS's new TPOC/WCMSA requirements, it is also important to consider how this new process impacts low dollar settlements. This is especially important given that CMS will now have visibility into an insurer's WCMSA practices not only for settlements that meet their review thresholds, but also for those settlement which do not meet their well-established thresholds. In the author's next article, this issue will be addressed, and we will learn how Verisk's new Data Driven MSA can help you.

Questions?

Please do not hesitate to contact the author at [email protected] or 978.825.8232 if you have any questions or would like to discuss how MSA Link can help you achieve better WCMSA compliance-related practices.

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