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.
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:
• 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.
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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