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CMS Self Administered Toolkit for WCMSA’s – Confusing Section


CMS Self Administered Toolkit

This article is a continuation of  the CMS Self Administered Toolkit.  The CMS (see yesterday’s J&L Blog article) has done a good job in attempting to provide injured employees with a guide if they decide to self-administer their WCMSA’s (Workers Compensation Medical Set Asides).   Most of the CMS Self Administered Toolkit seemed helpful until this section.

50 Medicare CMS Self Administered Toolkit Emblem from web

One blogger has suggested that the guide was not user-friendly.   I was going to disagree until I read this section.  One confusing area is trying to instruct the providers on how to bill for the charges.

What happens if the provider does not agree?   Are they under any obligation to bill at the rate requested by the patient?

How can an RX provider be required to pay AWP as described below?

The letters to use are not that great to instruct a provider how to bill for services.

Section 5: What to Tell Your Health Care  Providers 

Before you get treatment for your WC injury, you must advise your health care 
providers about your WCMSA. 

Your health care providers should bill you directly, and you should pay them out 
of your WCMSA account, IF: 

Picture Of Calculator and Financial Bill CMS Self Administered Toolkit On Table

• The treatment or prescription is for the WC injury, AND
• The treatment or prescription is something Medicare would cover.

How should my health care providers calculate the bill? 

You will need to know whether the WCMSA was set up based on full actual charges (the actual cost of the item or service). If so, health care providers may bill you according to full actual charges. 

On the other hand, if the WCMSA was funded based on a state (or federal) WC fee schedule (rates negotiated between WC and health care providers’ groups), the health care providers may bill you 
based on those fee schedule rates. 

Any prescription medications should be billed based on the Red Book Average Wholesale Price (AWP). Your provider will have access to this resource. 

Mid Adult Doctor CMS Self Administered Toolkit Explain

Tell your health care providers how your WCMSA was set up so they can bill you for your WC injury treatments using the correct pricing method. Note: Regardless of how you are billed by your health care provider, your WCMSA funds should be used to pay for your treatments. Sample letters for this purpose are included in  the Letters and Examples section of this Toolkit. 

If your health care providers mistakenly bill Medicare for your WC-injury-related treatment, remind them to bill you directly so you can pay them from your WCMSA account. Your health care provider is responsible for refunding any payments received from Medicare for bills related to treatment of the WC injury. 
What if my health care provider is also treating me for other problems? 

If your health care provider is also treating you for conditions not related to your WC injury, be very certain that you do not pay for such treatments using your WCMSA account. Use other insurance, including Medicare or your own funds. If you are not certain whether a treatment is related to your WC injury, ask your health care provider.  

Should the provider make basically a WC adjuster-type decision?

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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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