The Top 5 Reasons CMS Will Issue a Development Request

The Top 5 Reasons CMS Will Issue a Development Request

Nothing is more frustrating than reaching a workers’ compensation settlement only to have it delayed by weeks or months due to problems with the Medicare Set Aside (MSA) submission. One can easily jump to the conclusion that the Workers’ Compensation Review Contractor (WCRC) is an inefficient federal contractor who doesn’t care about your settlement. The reality is, the WCRC is averaging anywhere from 14-28 days from submission until approval on cases where all necessary information and documentation were provided. (Over the last year, we have received CMS approval on numerous submissions in under 10 days which is significantly quicker than the six-plus months it used to take.) So why does it still sometimes take much longer to get an MSA approved by CMS? The most likely cause of delay is the issuance of the dreaded “development request”. A development request is issued by CMS when the WCRC determines that not all of the required documentation was provided at the time of the original submission or that the documents provided reference other documents that they want to review. Sometimes the documentation isn’t provided at the time of submission because the party requesting the WCMSA did not have it and sometimes it simply no longer exists.

Knowing what causes a development request can help avoid unneccessary delays. According to CMS, the five most frequent reasons for development requests by the WCRC are:

1. Insufficient or out-of-date medical records;

2. Insufficient payment histories, usually because the records do not provide a breakdown for medical, indemnity or expenses categories;

3. Failure to address draft or final settlement agreements and court rulings in the cover letter or elsewhere in the submission;

4. Documents that are referenced in the file are not provided – this usually occurs with court rulings or settlement documents;

5. References to state statutes or regulations without providing sufficient documentation (i.e., to which payments the statutes/regulations apply or a copy of the statute or regulation, or notice of which statutes or regulations apply to which payments.)

Gathering all of the necessary documentation up front can avoid the dreaded development request and speed up the CMS approval process.

Source: Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (COBR-Q4-2020-v3.2)