Author Archives: Donna Mize, MSCC

CMS Expands Re-review Process

The long awaited update to the Workers’ Compensation Medicare Set-Aside (WCMSA) Re-Review process, as promised by The Centers for Medicare and Medicaid Services (CMS) in late December 2016, has arrived.

We reported in January through our blog entry, MSA Optimism for the New Year, CMS expected to update their Re-Review process sometime in 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 released an update to their Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Portal User Guide on July 11, 2017 (click here to access the updated guide) which includes the much-awaited information, starting in section 12.4 (page 12-12) titled “Submit a Re-Review Request for an Approved Case”.

Previously there were two Re-Review options (1 and 2 noted below). Now, CMS adds a third option referred to as the “Amended Review”.

  • Option 1:  You believe CMS’ determination contains obvious mistakes
  • Option 2:  You believe you have additional evidence, not previously considered by CMS, which was available prior to the submission date of the original proposal which warrants a change in the CMS’ determination.
  • Amended Review:  You believe projected care has changed so much the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

CMS specifies only one Amended Review is permitted per case and another re-review cannot be requested if a request for an Amended Review is denied. The following criteria have to be met for a case to be eligible for an Amended Review:

  • The case must have been originally submitted between one and four years from the current date and cannot have a previous request for an Amended Review
  • Must result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount

CMS has also noted as part of the re-review request, you may change from brand-named medications to generic medications and drug types. However, this change cannot be the sole reason for your re-review request. You must include additional changes (such as changes in dosage and/or frequency, additional medications, or medications no longer taken) to qualify for a re-review request.

The Amended Review process is a welcome change and we feel it will be a great benefit to the industry. This new process allows cases that have a CMS approved MSA, but did not settle to be re-evaluated for a more appropriate allocation based on current medical status. Although the Amended Review is limited to files with CMS submissions between one and four years from the current date, it is still great news for the MSA industry and a step in the right direction. One further change we would like to see is a formal appeals system put into place.

We recommend carriers and Third Party Administrators (TPAs) evaluate open cases to verify if any would fit the criteria for an Amended Review if medical circumstances have changed since CMS submission. The new criteria may provide a chance to settle the case where previously it was held up.

We anticipate there will be the potential for many cases which have not settled to take advantage of the Amended Review process. This could result in a CMS backlog for a short time while the industry is evaluating their caseload for opportunities. We anticipate the outcomes and potential reductions will allow files, where settlement was precluded due to a large CMS approved MSA’s, to be resolved. Please continue to watch this site for additional updates, news or trends as this new process unfolds.