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The Role of Primary Care Physician records in the CMS Review Process

It’s a dreaded situation that can bring the review process to a screeching halt. CMS wants current records, but the claimant hasn’t treated under workers’ compensation in years. One solution? Primary care physician records. But why would CMS want records from a claimant’s primary care physician? Better yet, how am I supposed to get those records when they are not being paid under the workers’ compensation system? Those are both very valid questions and the answers may help avoid an unnecessary delay in the CMS review process.

First, why would CMS want treatment records from a claimant’s primary care physician? The simple answer is that, in cases where treatment suddenly stops without reaching a conclusion, CMS wants to know what happened. If the claimant simply stopped treatment, CMS wants confirmation of the same. Alternatively, if the claimant moved treatment to another provider, CMS wants that information as well, along with copies of the records from the new physician. The hope is that in cases where the work-related treatment is not tied up with a pretty bow in the form of current treatment records or an explicit release from care, the primary care physician records will clarify the claimant’s current treatment status. In the event that the current primary care records make no mention of the work-related injuries, the records can be used to evidence no ongoing treatment. While the records alone may be sufficient to support the recent lack of treatment, this documentation may be most beneficial when used in conjunction with a statement from the last known treating physician confirming the last date of treatment.

The answer to how these records can be obtained is a little more complex and will vary state by state. In some cases, the records can be subpoenaed with the assistance of defense counsel. In others, a release signed by the claimant may be required. If you do not know the name of the claimant’s current physicians, reviewing the list of treatment providers on a conditional payment letter from Medicare is a great place to start. Cooperation from opposing counsel can also be a very beneficial tool. After all, the end goal of settlement is the same for each party!

In preparing our allocation reports, we will always provide a warning of when we expect that additional documentation will be requested by CMS. Proactively obtaining those documents can help ensure an accurate allocation and avoid unnecessary delays in the review process. If you have any questions regarding the CMS review process, or if we can provide assistance with the same, please feel free to reach out. We are happy to help!


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