As a data-driven company, we measure and watch the Centers for Medicare and Medicaid Services (CMS) Workers’ Compensation Review Center (WCRC) where workers compensation MSA (Medicare Set Aside) determinations are made. We compare each CMS determination against Care Bridge International’s proposed MSA for accuracy.
A consistent finding in the review of MSAs is the lack of transparency in the codes and prices sourced by the WCRC. Care Bridge International includes the nationally standardized treatment and procedure codes, with the associated state fee schedule price, for every future care recommendation. However, if CMS disagrees with our Medicare Set Aside result, countering with either a higher or lower amount, the differences are largely due to CMS errors in coding and price sources.
In other words, we often find that CMS used the wrong treatment / procedure code or used a code that will generate a higher price for treatment. CMS commonly “upcodes” physician office visits and diagnostic tests. Upcoding is considered fraudulent in medical billing. Upcoding means that a medical service performed was billed using a higher price than what should have been, based on the service that was performed.
Using data intelligence coupled with the identification of paid codes for a given claim, Care Bridge International identifies the most probable treatment code, given the severity of a medical condition.
We also identify errors in the utilization of care in the CMS review process. CMS often over-prescribes diagnostic tests and procedures, beyond what is reasonable and probable, as evidenced by medical data and evidenced based medicine.
CASE STUDY
In a recent CMS MSA review example, Care Bridge International recommended a total of 6 Synvisc injections, an injection used to lubricate and cushion the knee joint to provide pain relief. CMS recommended 96 injections. Care Bridge International responded to CMS explaining the actual dosing and use of Synvisc injections backed with scientific data and research. CMS re- reviewed our position and agreed with our original proposed 6 knee injections.
Recognizing these vulnerabilities in the CMS review process of MSAs at the WCRC level; it’s important that we carefully critique our work compared to that of CMS. Allowing the Re-Review process, CMS provides an opportunity for error correction.
Measuring claims post settlement, our Medicare Set Aside forecasts align closely with the actual medical incurred. This is another way that we measure the accuracy of our Medicare Set Asides, besides periodic independent actuarial reviews, so we are confident from both a domain knowledge and data perspective to defend our Medicare Set Asides and present sound logic in negotiating with CMS.
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Call Toll-Free: 888-434-9326 ext.101 or Email, Bob Schmidt, our Chief Client Officer at Bob@CareBridgeInc.com
