We are all aware that there are a number of steps in the WCMSA submission process. According to the latest WCMSA Reference Guide (Version 3.2; Section 9.4.3), these steps include the WCRC team reviewing “all the submitted records…taking into consideration the claimant’s specific condition [and] other comorbidities…”
Potential Impact of Comorbidities on MSAs
Comorbidities are multiple conditions present in an individual at the same time. But, what does that mean to me as a claims professional attempting to settle the claim? Whether or not an MSA is submitted to CMS, irrespective of the compensable or unrelated conditions, comorbidities can influence a claimant’s rated age and, by extension, their projected life expectancy. Thus, we begin by combing the records with an eye towards identifying all conditions that warrant inclusion in the rated age report. This is especially important for revised/updated MSAs, as there may be injuries or illnesses that have developed since the initial MSA and rated age report was created.
In contrast, for the MSA allocation itself, separating the compensable injuries from unrelated or resolved conditions is crucial. For example, it is not uncommon to find compensatory injuries – like the onset of left knee pain in response to favoring the initial industrial right knee, therefore potentially adding to the allocation. However, in one of our previous cases, the treating physician concluded that the left knee symptoms represented only a temporary strain. Upon examining the record further, the treating physician clarified that any further treatment to the left knee would not be due to the industrial injury claim, but rather to the claimant’s pre-existing and longstanding degenerative osteoarthritis. The treating physician added that the claimant’s eventual need for left total knee replacement was neither contributed to, nor hastened by, the temporary strain and thus our team could confidently omit the left knee from the allocation.
Catastrophic Claims Bring Unique Challenges
A recent MSA referral involved industrial “black lung disease” in a coal miner who ultimately underwent a double lung transplant. In our review of the most recent medical treatment records, the claimant was faring quite well now several years following transplantation. The claimant remained active and independent in all activities of daily living, with the mainstay of treatment being anti-rejection medication and intermittent follow-ups with a pulmonologist.
But we also noted ongoing visits to a dermatologist for monitoring and treatment of squamous cell carcinoma. It is known that the use of anti-rejection medications can compromise the immune system – including its ability to repair or destroy UV-damaged skin cells – and thus the incidence of squamous cell carcinoma increases significantly in transplant recipients. Similarly, the records referenced concurrent treatment for diabetes, and indeed the treating internist linked this to the long-term use of corticosteroid medication post-transplant (i.e., steroid-induced diabetes mellitus). We identified that not only were the specialists managing these complex, comorbid conditions members of the medical center’s transplant department, but that payments were authorized for their services.
Navigating Complex Claims
Given their complexity, such claims can be overwhelming. In the case above, our experienced team helped the client navigate the associated (and compensable) comorbidities toward creating a defensible, evidenced-based MSA and also avoiding any surprises of exposure for treatment that CMS would otherwise reasonably relate to the initial injury, as part of the CMS review process. This also afforded the claims team with the opportunity to re-evaluate authorization of services to verify their position, as well as consider whether there was an opportunity to mitigate treatment costs prior to submitting the MSA to CMS for review.