Updated WCMSA Reference Guide Provides Insight into Surgery Pricing

2.3.2021 Blog

On October 5, 2020, CMS released version 3.2 of its Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide.  One of the changes provided further guidance on how the Workers’ Compensation Review Center (WCRC) prices surgical procedures in WCMSAs.  This is a welcomed step toward greater transparency in pricing of surgical procedures in CMS-approved WCMSAs.  We previously wrote about the lack of guidance in how CMS priced surgeries.  The updated Reference Guide includes an appendix identifying which hospitals or major medical centers the WCRC uses to calculate surgery facility fees in WCMSAs.

Surgery fees are comprised of several factors and variables, the largest of which is often facility fees.  Facility fees are generally calculated using several factors: the procedure codes for the type of surgery being performed; the type of setting or facility where the procedure is being performed; and the specific hospital or geographic region.  Despite the many factors involved, CMS lumps all these variables (including professional and anesthesia fees) into one amount without providing any details of how it arrived at the totals.  Prior to the October 2020 updates, the WCMSA Reference Guides stated that the WCRC used pricing for major medical centers within the state or appropriate fee jurisdiction.  However, CMS provided zero guidance on how they selected the major medical center or which ones were actually used when pricing WCMSAs.

The new Reference Guide provides one piece of the puzzle to assist allocators and secondary payers in estimating surgery pricing in proposed WCMSAs.  However, there remain other unknown variables, including what procedure codes and what type of facility or surgical setting WCRC is using to price certain surgeries.

We will continue to monitor and provide updates on developments with CMS’s procedures. In the meantime, if you have any questions about prospective surgical pricing in WCMSAs, or Medicare compliance in general, the attorneys at Nyhan, Bambrick, Kinzie & Lowry, P.C. are always available to assist.

The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information.  Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.