CMS Proposes Expansion of the WCMSA Re-review Process

CMS, Medicare Set-Aside Blog, Medicare Set-Asides, News and Events on February 12, 2014
Posted by Kimberly Wiswell

On February 11, 2014, CMS released a request for comments concerning an expansion of their Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) re-review process.  In the past, requests for re-reviews have been limited to situations where the submitter omitted documentation or information from the original submission or where a mathematical error was made by the review contractor.

Their current proposal to expand the re-review process includes a broader array of categories and reasons, as well as a resolution timeframe of 30 business days. It goes on to state that the re-reviews will be handled by experts who are best skilled to review the identified issue and different from those who originally provided the approval review.

Under their proposal, the re-review requests would be limited to situations where: the WCMSA approval had been approved in the last 180 days; the case had not settled; no prior re-review request had been submitted; and the re-review requests a change to the approved amount equivalent to the greater of either 10% of the approval or $10,000.

The expanded reasons include:

  • Submitter disagrees with how the medical records were interpreted.
  • Items or services priced in the approved set-aside amount are no longer needed or there is a change in the beneficiary’s treatment plan.
  • A recommended drug should not be used because it may be harmful to the beneficiary.
  • Dispute of items priced for an unrelated body part.
  • Dispute of the rated age used to calculate life expectancy.

The proposal goes on to suggest that some re-review requests may be elevated to a CMS Regional Office, where they involve issues such as failure to adhere to court findings; CMS policy disputes; or a payer maintaining Ongoing Responsibility for Medicals (ORM) where such treatment has been included in the approved WCMSA.

CMS has requested comments be provided by March 31st to [email protected]. A town hall conference will be held in the future prior to implementation to discuss the expanded re-review process.

So what does this mean for you?   For starters, it gives hope to those that choose to utilize the voluntary review process.  Hope that their allocation will be reviewed with common sense and understanding of the issues involved in the case.  Hope that an approval will be forthcoming based on realism, and not proceduralism (not a word, but you know what we mean).  For the skeptics, it means that a review process may be coming, however, given the number of cases where re-review will be requested, a 30-day turnaround time seems ambitious, and there is no guarantee they will agree with your position even after re-review.

We applaud CMS for taking steps to improve their voluntary review process, however, the question still remains as to what value their review really brings to the settling parties in the first place.