Eyes on the Prize: A New CMS Re-Review Option is Available.

CMS, Medicare Set-Aside Blog, Medicare Set-Asides, MSP News, WCRC on July 10, 2017 | Posted by Jean S. Goldstein, JD

While all eyes (and ears) have been focused on the news, or the lack thereof of news regarding the Workers’ Compensation Review Contractor award, CMS quietly released a change to their re-review process today.  The change was released through CMS’ Workers’ Compensation Medicare Set-Aside Portal (WCMSAP).  Specifically, through a revised WCMSAP User Guide, which can be found here.

As you will recall, in December 2016 CMS announced possible expansion to the re-review process, as reported here on our blog.  Within the revised user guide, it appears that CMS has expanded the re-review process by creating an “Amended Review” option available through the portal.  The re-review process has been expanded to accommodate situations where projected care for a case has changed such that the new proposed settlement amount differs from the CMS approved MSA amount by 10% or $10,000, whichever amount happens to be greater.  Medical or prescription drug details must be provided to support the amended review request with supporting documentation.  This type of review may only be submitted one time per case.  If the amended re-review request is not approved, another amended re-review request may not be submitted.  As indicated within CMS’ revised guide, in order to exercise the amended re-review option, the following criteria must be met:

  • The MSA must have been originally submitted between one and four years from the date the re-review is submitted (meaning that very recently approved cases are not eligible for this re-review process);
  • The re-review request cannot have had a previous request for an Amended Review; and
  • Must result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

Selecting this amended re-review option in the CMS portal, requires that a new proposed MSA amount be provided, which again must result in a difference of at least 10% or $10,000.  Under this process, CMS also requires that additional medical details are provided such as the type of additional medical treatment being required, or specifically noting which treatment/care is no longer required.  Overall, this amended re-review option allows for changes in care to be accounted for by CMS.  In addition, this new re-review option also allows for a re-review based on changes from brand-name to generic drugs and drug types, but a brand name to generic drug change cannot be the sole reason for the re-review request (additional changes, such as dosages, frequency, etc) must be accompanied to qualify for such medication changes under this new re-review request option.  Under the amended review option, CMS will consider medical treatment records dated after the original CMS submission date.  Again, the caveat to this re-review process is that the MSA must have been originally submitted between one and four years from the date the amended review request is submitted.

Some additional changes have also been made in the portal.  Specifically, submitters must now attest that the documentation provided is complete and accurate to the best of their knowledge, prior to being able to submit an MSA.  Medicare beneficiaries will also now have access to any of their existing workers’ compensation cases submitted through the portal which will allow a Medicare beneficiary access to view case information and associated documentation in their MyMedicare account profiles.  In addition, for those cases where a case has been closed for over a year due to lack of information where a closeout letter has been issued, cases will need to be resubmitted as when submitting a new MSA submission; including documentation for the past two years. We would expect a more formal announcement regarding these news processes and changes to be issued shortly by CMS.

As you know, we have been advocating for expansion of the re-review process for quite some time.  We are happy to see the amended review process will be available for our clients who choose to utilize CMS’ voluntary submission program.  However, only time will tell of the successes of this new re-review option.  Stay tuned for more information regarding this new re-review process, the WCRC contractor status, and additional MSA review changes as they develop.