News

Did you miss it?
August 13, 2017

If you were unable to attend the “You Asked for WCMSA Re-Review & Medicare Answered: New Amended Review Process” webinar, you can watch it here now.

New Medicare Cards Are Coming
July 29, 2017

On July 27, 2017, the Centers for Medicare and Medicaid Services (CMS) released notification that they renamed the project aimed at removing Social Security numbers from Medicare cards. Up until now, CMS referred to the project as the "Social Security Number Removal Initiative" (SSNRI). The project is now titled the "New Medicare Card" project.

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Expanded Re-Review Process for MSAs Among Changes Announced in the WCMSA Portal User Guide Update
July 11, 2017

On July 10, 2017, the Centers for Medicare and Medicaid Services (CMS) released updates to its user guide for the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP). You may find a copy of the updated version (version 5.1) here. Below is a summary of the changes, and information on how these changes may impact your claims.

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Movement in the MSP Compliance Realm? Update on Liability and No-Fault Medicare Set-Asides
July 9, 2017

In a previous Industry News Bulletin, we noted that CMS seemed to be taking affirmative first steps on Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs). Since the time of that writing, we have seen a few revisions to the change request notice provided to Medicare Administrative Contractors (MACs). The most recent revision to the change notice was released on June 8, 2017. This change request issued by the Centers for Medicare and Medicaid Services (CMS) to its contractors continues to outline a timeline for back-end technical changes to modify Medicare’s Common Working File (CWF) to address LMSAs and NFMSAs.

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Why does the MSP industry use the phrase "consider and protect" when discussing Medicare's interest?
June 29, 2017

Recently you may have seen some back and forth about the plain language of the Medicare Secondary Payer (MSP) Statute found at 42 USC 1395y(b). The discussion focused on why the industry uses the phrase "consider or protect" when discussing Medicare compliance when those two words are found nowhere in the plain language of the statute and regulations (42 CFR 411 et seq.). 

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Effective October 31, 2017, There is a New Law Governing Closeouts of Future Medicals in Arizona Workers’ Compensation Settlement Agreements
June 16, 2017

On May 8, 2017, Arizona Governor Doug Doucey signed an amendment impacting the workers’ compensation law governing settlements that close out future medical treatment on admitted claims. The legislature voted to repeal Section 23-941.01[i] and replace it with an amended version[ii]. The old version allowed release of future supportive medical maintenance benefits, but disallowed closure of active treatment in admitted claims. The new amendment is effective as of October 31, 2017 and allows the closure of all future medical benefits by way of a settlement agreement if specific criteria are met.

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A First! FDA Requests Withdrawal of Opana® ER from the Market
June 12, 2017

In the midst of an “unprecedented opioid epidemic” (per the federal Department of Health and Human Services), the U.S. Food and Drug Administration (FDA) asked for withdrawal of Opana® ER from the market, a first ever! FDA Commissioner Scott Gottlieb states the opioid epidemic is a public health crisis and all necessary steps must be taken to reduce the scope of opioid misuse and abuse.

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As the Commercial Repayment Center Turns; Must Practices in Handling Condition Payments
March 14, 2017

The Commercial Repayment Center (CRC) has been on the job for the last eighteen months. It’s time for a progress report on this contractor, which has reset the timeline for conditional payment investigations.

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California to Roll Out Formulary July 1st 2017 - The Good and the Bad of Drug Formularies
March 7, 2017

At the most recent Department of Workers’ Compensation (DWC) Educational Conference held on February 23rd, George Parisotto, Acting Administrative Director Division of Workers’ Compensation, updated attendees on the status of the development of the California formulary. The formulary is set to go live on July 1st, 2017, and will be based on medical treatment standards set by the American College of Occupational and Environmental Medicine (ACOEM) in an effort to remain consistent with the Medical Treatment Utilization Schedule (MTUS) guidelines.

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SPARC Act Re-Introduced in Congress: Adjusters and Attorneys on Notice
March 1, 2017

On February 17, 2017, Congressman Tim Murphy (R-PA) re-introduced the Secondary Payer Advancement, Rationalization, and Clarification Act, or SPARC Act. The bill is styled as HR 1122 and is co-sponsored by Rep. Ron Kind (D-WI). The aim of the SPARC Act is to clarify the Medicare Secondary Payer (MSP) program when Medicare Part D is involved.

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CMS Takes First Steps on LMSAs
February 26, 2017

Last week CMS released a change request to modify Medicare’s Common Working File (CWF) to address a new Liability Medicare Set-Aside (LMSA) policy. The announcement establishes a timeline for back-end technical changes and provides clues to Medicare’s new policy. A copy of the notice can be found here.

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Summary of the SSN Removal Initiative Open Door Forum; One Key Field Name Change
January 19, 2017

Summary of the SSN Removal Initiative Open Door Forum; One Key Field Name Change On January 17, 2017, the Centers for Medicare and Medicaid Services conducted a Special Open Door Forum to discuss the proposed changes in accordance with the Social Security Number Removal Initiative (SSNRI) of Section 501 of the Medicare Access and CHIP Reauthorization Act (MACRA).

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California Federal Court: CMS May Not Seek Reimbursement for Conditional Payments That are Unrelated to the Claim
January 12, 2017

On January 5, 2017 in the matter of California Insurance Guarantee Association (CIGA) v. Burwell(i), a Federal Court granted CIGA's Motion for Partial Summary Judgment and ruled that the Centers for Medicare and Medicaid Services (CMS) may not seek reimbursement for items or services unrelated to work injuries claimed by beneficiaries who were also covered by CIGA's policies. This case pronounces that CMS may only seek reimbursement for items and services related to the claim, which may be separate from other items and services billed by a provider under a date of service.

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Open Door Forum Re: SSN Removal
January 2, 2017

On Tuesday, January 3, 2017, the Centers for Medicare and Medicaid Services (CMS) scheduled a Special Open Door Forum to allow Medicare Secondary Payer (MSP) stakeholders the opportunity to learn and ask questions about upcoming changes to the Social Security Number-based Health Insurance Claim Numbers (HICNs). This conference call is a follow-up to the May 2016 informational bulletin regarding Section 501 of the Medicare Access and CHIP Reauthorization Act (MACRA), which requires CMS to remove SSNs from Medicare ID cards by April 16, 2019.

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CMS to Update WCMSA Re-Review Process in 2017
December 22, 2016

CMS announced yesterday that it expects to update its existing WCMSA re-review process. CMS indicated it plans to implement processes in calendar year 2017 to “address situations where CMS has provided an approved amount, but settlement has not occurred and the medical care that supported the approved amount has changed substantially.” CMS also stated it expects the updated process to address situations where certain states rely on Utilization Review Processes to justify proposed WCMSA amounts.

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CMS Reduces Liability Reporting Threshold to $750 for 2017
December 12, 2016

After announcing last month that CMS was reducing the recovery threshold for physical trauma-based liability settlements from $1,000 to $750 for 2017, CMS has now issued an Alert that as of 1/1/2017 the mandatory reporting threshold for liability insurance Total Payment Obligation to the Claimant (TPOC) Amounts dated 1/1/2017 or after is changing from $1,000 to $750. CMS further announced that in 2017 it will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals (ORM).

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ExamWorks Clinical Solutions and Chronovo Announce iMSA; Structured Settlement Solution Improves Settlements for All Stakeholders
November 29, 2016

Lawrenceville, GA., November 28, 2016 – ExamWorks Clinical Solutions (ECS) announced today an exclusive agreement with structured settlement broker, Chronovo, to deliver an innovative solution to the Medicare Set-Aside (MSA) space for workers’ compensation and liability settlements, called the iMSA.

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CMS Reduces Liability Recovery Threshold to $750 for 2017
November 16, 2016

After announcing two months ago that CMS was maintaining the recovery threshold for physical trauma-based liability settlements at $1,000 for 2016, CMS has now issued an Alert that as of 1/1/2017 the liability recovery threshold will be reduced to $750.  CMS further announced in this 11/15/2016 Alert that in 2017 it will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals. 

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CMS Improves Functionality and Access to MSPRP
November 9, 2016

The Centers for Medicare and Medicaid Services (CMS) released an updated version of the Medicare Secondary Payer Recovery Portal (MSPRP) User Guide (Version 3.5) which documents improved functionality and access on the MSPRP including portal use for matters pending with the Commercial Repayment Center (CRC). Given the delays in obtaining documentation from the CRC, the expansion of the portal to cover claims with the CRC is an improvement in CMS’s Medicare conditional payment processes.

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CMS Announces Rollback of Rule Change Impacting Legal Zero MSAs
November 1, 2016

ExamWorks Clinical Solutions recently issued an Industry News Bulletin concerning an abrupt rule change to a long-standing CMS policy regarding approval of Legal Zero MSAs (see article here).  CMS provided no notification of the rule change prior to the rule’s implementation by the Workers’ Compensation Review Contractor (WCRC).  Accordingly, following our confirmation of the rule change with the WCRC, we immediately placed all Legal Zero MSA matters on hold and voiced ours concerns regarding this unannounced rule change to the CMS Central Office in Baltimore. 

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CMS Implements Rule Change to Long-Standing Legal Zero MSA Policy; New Document Submission Required; Recommended Procedural Options
October 27, 2016

ExamWorks Clinical Solutions (ECS) was advised by the Centers for Medicare and Medicaid Services (CMS) that a Legal Zero MSA (“no liability” or “Zero allocation” MSA) based solely upon the employer or carrier’s complete denial of the claim will not be approved. Such a denial is typically evidenced by a claim payment history documenting no payments for medical treatment and indemnity and a letter from the adjuster or defense attorney confirming such a denial.

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CMS Implements $750 Settlement Threshold for WC Conditional Payment Recovery; Maintains $1,000 Threshold in Liability
September 27, 2016

A September 26, 2016 CMS Alert (Alert) announced the implementation of a $750 conditional payment recovery threshold for no-fault and workers’ compensation settlements.  CMS also announced it is maintaining the $1,000 conditional payment recovery threshold for liability settlements, a threshold which has been in place since January 1, 2014.

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Federal Appellate Court Holds Medicare Advantage Plan Assignees May Maintain Claims for Reimbursement Against No-Fault and PIP Plans
September 26, 2016

The 11th Circuit U.S. Court of Appeals, which includes Florida, Alabama and Georgia under its jurisdiction, has found that Medicare Advantage Plans (MAPs) may assign their rights of recovery under the MSP Act to another party.  The consequence of the ruling is that MAPs or their assignees may assert a claim for reimbursement against no-fault and personal injury protection (PIP) plans for payments made by the MAPs deemed to be related to a claimed injury, including a claim for double damages. 

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Medicare Advantage Plans Prevail Again Before a Federal Appeals Court
August 23, 2016

Double Damages and MAPs – What You Need To Know: On August 8, 2016, the U.S. Eleventh Circuit Court of Appeals upheld an order from the lower federal district court granting summary judgment in favor of Humana[i] regarding Western Heritage Insurance Company’s (Western’s) obligation to reimburse Humana for Medicare benefits paid on behalf of its Medicare Advantage plan enrollee, Mary Reale, and its claim for double damages pursuant to the Medicare Secondary Payer Act (MSP).   In affirming the district court’s order, the Eleventh Circuit specifically agreed with and adopted the Third Circuit Court of Appeals’ reasoning and holding in In re Avandia[ii] a prior successful decision for Medicare Advantage plans

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Removal of SSN from Medicare Cards to Impact MSP Compliance
June 21, 2016

A law passed in 2015 eliminated Social Security Numbers (SSNs) from Medicare ID cards, also known as Health Insurance Claim Numbers (HICNs).  Congress and the President required use of a MBI to minimize the risk of identity theft for Medicare beneficiaries and to reduce opportunities for fraud within the program.

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CMS Considers New Effort to Expand MSA Review Process to Liability
June 10, 2016

The Centers for Medicare and Medicare Services (CMS) is considering expanding the voluntary Workers’ Compensation MSA review process to include review of liability and no-fault insurance MSA amounts.   The June 9, 2016 notice states as follows:

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CMS Publishes Alert for Additional Excluded ICD Codes for Section 111 Reporting
May 25, 2016

On Monday, May 23, 2016, the Centers for Medicare & Medicaid Services (CMS) published a Technical Alert regarding new excluded diagnosis codes.  The alert can be found here.

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CMS Final Rule for Process and Timeline to Obtain Final MSP Conditional Payment Amounts via Web Portal
May 23, 2016

On May 17, 2016, the Centers for Medicare and Medicaid Services (CMS) published a final rule entitled “Medicare Program: Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal”.  While the rule will be effective June 16, the process defined by the rule was initiated by CMS in December 2015. See prior ECS article "CMS Initiates Process Allowing for Obtaining Final Conditional Payment Amount Pre-Settlement".  The final rule provides the official guidance on the how and when this Pre-Settlement Final Conditional Payment process may be utilized by the settling parties.

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CMS Releases Bulletin Explaining Delay in Issuance of CPLs, CPNs and Demand Letters
February 11, 2016

CMS published a Bulletin on February 9, 2016 addressing issues encountered in implementation of Conditional Payment recovery actions against insurers. See bulletin here. According to CMS, the CRC has issued more than 33,000 Conditional Payment Letters (CPLs) and Conditional Payment Notices (CPNs) since the transition. CMS advised that it is aware that many insurers and WC entities are awaiting CPLs, CPNs, or demand letters. CMS has engaged with the CRC to improve responsiveness to requests for conditional payment information and the handling of correspondence.

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California Independant Medical Review Determinations More Widely Accepted by CMS
January 26, 2016

One of the most significant recent developments in limiting unnecessary medical care costs in California workers’ compensation came with the July 1, 2013, implementation of the Independent Medical Review (IMR) process. The IMR statute allows workers’ compensation claimants to appeal Utilization Review (UR) denials of medical care with the resulting IMR determination binding upon the parties. Initially, the Centers for Medicare and Medicaid Services (CMS) refused to recognize IMR determinations as providing a basis for limiting medical care in a Medicare Set Aside (MSA), thus maintaining their normal practice of largely relying upon the opinions and recommendations of the treating physician to allocate future medical care. More recently, ExamWorks Clinical Solutions (ECS) has identified favorable trends in CMS recognition of IMRs in MSA submissions.

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Takemoto False Claims Act Case Dismissed
January 23, 2016

A suit under the Federal False Claims Act against more than 50 insurance stakeholders filed in the U.S. District Court for the Western District of New York has been dismissed. In 2011, Dr. Kent Takemoto filed this action to recover damages and civil penalties on behalf of the United States of America arising from insurers and self-insured companies for their alleged failure to repay known government obligations in violation of the Federal False Claims Act, 31 U.S.C. §§ 3729 et seq. Specifically, the suit requested damages for failure to comply with the obligations imposed by the Medicare Secondary Payer ("MSP") statute, 42 U.S.C. § 1395y(b)(2).

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ECS Web Presenation: Guide to the new CMS Pre-Settlement Final Conditional Payment Amount Process
January 10, 2016

In late December CMS launched the long-awaited process for obtaining the final conditional payment amount prior to settlement. The process is very rigid in its requirements making very easy for one to run afoul of its strict timelines. ExamWorks Clinical Solutions is pleased then to offer this one-hour web presentation which will provide attendees a how to guide for utilizing this new process to obtain the final conditional payment amount pre-settlement. The presentation will also update attendees with the latest on actions by CMS's Commercial Repayment Center (CRC) to recover for conditional payments made during periods of ongoing responsibility for medical by the employer or insurer.

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CMS Initiates Process Allowing for Obtaining Final Conditional Payment Amount Pre-Settlement
December 31, 2015

On Monday, December 21, 2015 the Centers for Medicare and Medicaid Services  (CMS) published an Alert entitled: Modification of the Medicare Secondary Payer  Recovery Portal (MSPRP) for Inclusion of Final Conditional Payment (CP) Process  Functionality. CMS has completed the implementation of an electronic  method that allows claimants or their authorized representatives to obtain the  final conditional payment amount within three days of final settlement as  opposed to initiating lien investigation and resolution in anticipation of settlement  without a concrete time frame. The process through the MSPRP is very rigid in its  requirements which may limit its usefulness to parties settling workers’  compensation and liability cases.

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CMS Webinar Expounds on Commercial Repayment Center Procedures
September 2, 2015

On Tuesday, August 23rd, 2015 CMS held a webinar further explaining the new  policies and procedures for conditional payment recovery through the  Commercial Repayment Center (CRC) and the Benefits Coordination and Recovery  Center (BCRC). On July 1, 2015, CMS first announced that it would be transitioning  a portion of the NGHP recovery workload from the Benefits Coordination &  Recovery Center (BCRC) to the CRC. CMS explained that the transition was part of  a continuing effort to improve the conditional payment recovery and its accuracy  in Medicare Secondary Payer (MSP) situations.

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Legal Update on Medicare Advantage Plan Recovery Rights
August 23, 2015

The latter half of 2014 and, thus far, 2015 have been busy times for Medicare  Advantage Plans (MAPs) seeking clarification of their rights under the Medicare  Secondary Payer (MSP) Act. MAPs, or “Part C providers” argue that the MSP Act  and federal regulations outlining the right of Medicare Advantage Organizations  are broad enough to allow providers of Medicare benefits to enjoy the same  federal preemptive rights that Medicare Parts A and B routinely resort to when  seeking recovery against settling parties. They argue that they are entitled to  maintain a private cause of action against insurers who fail to reimburse them for  care provided to a Medicare beneficiary and to recover double damages from  those entities.

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CMS Publishes Updated NGHP User Guide to Include Recent Alerts and the NGHP Town Hall Teleconference
July 13, 2015

On Monday, July 13th, 2015 the Centers for Medicare and Medicaid Services (CMS) published version 4.7 of the MMSEA Section 111 Non-Group Health Program (NGHP) User Guide, found here.

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CMS Announces Upcoming Transition of Portion of the Non-Group Health Plan Recovery Workload to the Commercial Repayment Center
July 5, 2015

On July 2, 2015, the Centers for Medicare and Medicaid Services published a bulletin outlining a change in procedure regarding Medicare Secondary Payer situations and limiting Medicare payments where Ongoing Responsibility for Medicals (ORM) exists.

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CMS Announces Solution to Partial Social Security Number (SSN) Query Matching Process
June 18, 2015

The Centers for Medicare and Medicaid Services (CMS) has resolved the issue with the Section 111 mandatory reporting Medicare Eligibility Query matching process in which submission of a partial social security number (Last 5 digits) may result in claimants incorrectly being identified as Medicare beneficiaries. The prior announcement may be found here.

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Partial Social Security Number (SSN) Query Issue at CMS
June 1, 2015

The Centers for Medicare and Medicaid Services (CMS) has discovered an issue with the Medicare Eligibility Query matching process when only a partial social security number (Last 5 digits) is provided. Partial social security number queries are a portion of the changes made to the Medicare reporting process with the enactment of the Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2012.

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CMS Publishes Further Explanation of Appeal Rights for Applicable Plans
April 28, 2015

On April 22, 2015, CMS published a downloadable document further explaining the recently available appellate rights granted to applicable plans/primary payers where Medicare seeks Medicare Secondary Payer (MSP) recovery directly from those applicable plans. The document can be found here. The CMS publication follows the final rule implementing certain portions of the Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2012. Prior to passage of the Act, only Medicare beneficiaries were empowered to formally appeal the amounts to which Medicare claimed as reimbursable for treatment that is the responsibility of an applicable plan.

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CMS Issues Final Rule Implementing Appeal Provisions of the SMART Act
March 1, 2015

On Friday, February 27, the Centers for Medicare and Medicaid Services published its final rule implementing provisions of the Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2012 regarding the appeals process for liability insurance (including self-insurance), no-fault insurance, and workers' compensation laws or plans when Medicare pursues a Medicare Secondary Payer (MSP) recovery claim directly from those entities (here).

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ExamWorks Clinical Solutions Will Implement New File Specifications
February 12, 2015

Over the last year, the Centers for Medicare & Medicaid Services (CMS) has issued three key Alerts related to Mandatory Insurer Reporting.

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CMS Extends Development Letter Response Time in Updated WCMSA Reference Guide
January 15, 2015

On January 5, 2015, the Centers for Medicare and Medicaid Services (CMS) released an updated WCMSA Reference Guide, Version 2.3, which can be found here. The WCMSA Reference Guide provides the policies and procedures by which CMS and its contractor review Workers' Compensation MSAs submitted for approval. Since first being released in March 2013, CMS has made several updates to the guide.

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CMS Publishes Updated NGHP User Guide to Include Recent Alerts
January 13, 2015

On Tuesday, January 6, 2015 the Centers for Medicare and Medicaid Services (CMS) published version 4.4 of the MMSEA Section 111 Non-Group Health Program (NGHP) User Guide.

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ExamWorks Clinical Solutions
June 5, 2014

ExamWorks Group, Inc. announced that the Company completed the acquisition of Ability Services Network, Inc. (“ASN”) and its subsidiary MedAllocators, Inc. (“MedAllocators”). The acquisitions of ASN and MedAllocators follows the Gould & Lamb acquisition completed in February 2014. ExamWorks also announced the creation of ExamWorks Clinical Solutions to manage its expanding Medicare compliance business.

Events

CMS to Host Town Hall Teleconference with CRC officials
November 12, 2016

CMS has announced a Town Hall teleconference on November 17, 2016 to discuss the improvements to the MSPRP and the following topics:

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