Newsflash: CMS Alert

CMS Updates for 2017

On 12/21/2016, CMS announced that in 2017 it will update its existing re-review process to specifically address cases where settlement has not occurred and a Claimant's care has changed substantially since CMS issued an approval. In the announcement CMS stated that it expects its updated process to address situations where certain states rely on Utilization Review to justify proposed WCMSA amounts.

Currently, re-review of a CMS approved Medicare Set Aside (MSA) is limited to two specific situations:
1) When CMS' determination contains obvious mistakes, such as a mathematical error; or
2) When there is additional evidence not previously considered by CMS, which is dated prior to the submission date of the original CMS submission, and which warrants a change in CMS' determination.

Stay tuned for further updates.

For more information, please contact FRR's Paige O'Connor.


Newsflash: CMS Alert

CMS recently announced a change in the reporting thresholds to $750 for liability settlements, and advised that it would keep the $750 threshold for no-fault and workers' compensation settlements, where the insurer does not otherwise have ongoing responsibility for medicals (ORM). Yesterday, CMS issued an alert regarding these changes which can be found here.

As 2017 approaches, we wanted to clarify CMS' updates as follows:
- For Liability Insurance Cases: The mandatory reporting threshold for total payment obligation to the claimant (TPOC) after January 1, 2017, has changed from $1,000 to $750. If the most recent TPOC date is after January 1, 2017 and the TPOC amount is greater than $750, the TPOC must be reported.
- For No fault Insurance Cases: The mandatory reporting threshold for TPOC amounts dated October 1, 2016 or after, changed from $0 to $750. If the most recent TPOC date is after October 1, 2016 and the TPOC amount is greater than $750, the TPOC must be reported.
- For Workers' Compensation Cases: The mandatory reporting threshold for TPOC amounts dated October 1, 2016 or after changed from $300 to $750. If the most recent TPOC date is after October 1, 2016, and the TPOC is greater than $750, the TPOC must be reported.

Another change for 2017 is that reporting for cases below the required reporting threshold will be accepted, but are not required. CMS' recent alert states that until January 1, 2017, cases with amounts less than the required reporting threshold will be rejected unless reported with ORM. After January 1, 2017, cases will only be rejected if the case is noted as having no ORM, and for which the total TPOC amount is $0. For more information on mandatory reporting or how the reporting thresholds will affect your case, please contact FRR's Paige O'Connor.


Newsflash: Medicare Updates


In the past year, Medicare has made changes to the way workers' compensation insurers dispute and pay conditional payments made on behalf of Claimants that are Medicare recipients. Under the new rules, Workers' Compensation Insurers must report workers' compensation claim information to CMC by submitting an electronic file or filing through the Section 111 COB secure website. Insurers will receive a Conditional Payment Notice from the CRC detailing those payments that CRC believes the insurer is responsible for, along with a notice of the time allowed to dispute those payments. If you reported the claim, you MUST file any dispute within 30 days of the date of the Conditional Payment Notice. Disputes can be filed electronically or in writing. After 30 days, a demand letter will be issued listing all conditional payments owed to CRC. You have 125 days from the date of the demand to appeal. Appeals must be accompanied by proof of representation. Interest accrues on the conditional payments from the date of the demand letter. Once the demand is paid in full, you will receive a letter indicating that debts have been satisfied. Of note, CMS issued an alert on 09/29/2016 implementing a $750 threshold for no-fault insurance and Workers' Compensation entities. This new threshold means that CMS will not seek recovery of conditional payments made on Workers' Compensation or no-fault claims falling under the $750 threshold.

The alert can be found here:
The threshold methodology can be found here:


Newsflash: New Business Partnership


First Rehabilitation Resources, Inc. (FRR) is pleased to announce a new strategic alliance with IMX Medical Management Services, Inc. (IMX).

-IMX is located in Malvern, PA (suburban Philadelphia), and was founded in 1995 by David Dugery and John Sivel

-IMX maintains URAC accreditation as an Independent Review Organization (IRO).

-IMX provides a full array of medical evaluation and review services (IMEs, FCEs, Record Reviews, etc.) primarily in Pennsylvania, New Jersey and Delaware in addition to a boutique case management practice in Pennsylvania.

-Janet Dayhoff and her Team will continue to run FRR as a separate, sister Company to IMX, with the day-to-day operations continuing in Maryland.

-FRR and IMX share similar corporate cultures and a dedication to providing the highest level of service to our clients and the industry.

-Our goal with the affiliation is to have the organizations collaborate closely to aid in the continued expansion of both.


Newsflash: Pain Management Services


First Rehabilitation Resources, Inc. (FRR) is pleased to announce Nurse Case Manager, Bonnie Painter, RN, CCM, is now Registered Nurse-Board Certified (RN-BC) in Pain Management Nursing. Bonnie is the first member of our staff to have pursued this credential.

Prior to working at FRR, Bonnie worked with Orthopaedic Surgeons in acute care hospital settings to include critical care areas, as well as with Health Insurance Companies completing concurrent reviews for inpatient hospital admissions. In July 2011, Bonnie became a valued member of our Nurse Case Management Team, managing both Field and Telephonic Cases, with specialties including Cardiac, Trauma, Utilization Review, and now, Pain Management. As per the American Nurses Credentialing Center (ANCC), eligibility to apply for a Pain Management Nursing Certification includes holding a current, active RN license, and having practiced in a Nursing role involving Pain Management for at least 2,000 hours in the 3 years prior to applying for the examination. Additionally, continuing education requirements must be met.

The Pain Management certification is renewed every 5 years. The required 75 hours of CEUs must be half professional development, and the other half may be fulfilled with academic credits, presentations, publication or research, preceptor hours or professional service. Some focus must be placed on Pharmacotherapeutics.

As the Medical Management of Chronic Pain continues to be a hot topic in our industry, FRR currently offers a variety of resources to review and manage files involving chronic, high level opioid usage. FRR reviews cases for Medication Reconciliation, coordinates Independent Medical Examinations to determine ongoing needs, meets with Treating Physicians to discuss current treatment regimes, and prepares files for Utilization Review. Use of the standardized morphine equivalent calculator (developed by the Washington State Agency Medical Directors' Group), in conjunction with the Interagency Guidelines (developed for opioid dosing for Chronic Non-cancer Pain), assist in determining a measurable daily dosage, particularly when multiple medications are in play.

To learn more about our Pain Management Program or to submit a referral:, 301.369.3401