A New Day for WCMSA Amended Review Requests Start April 7th

March 19, 2025 / 5 min read

As we head into April, there is much focus on the Centers for Medicare and Medicaid Services (CMS’s) new TPOC/WCMSA reporting requirements starting April 4, 2025. However, it is important not to forget another new WCMSA update that becomes effective in April. Specifically, effective April 7, 2025, CMS will now allow parties to submit Amended Review requests at any time after a WCMSA case is approved by CMS.^[1]

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This new update eliminates CMS’s long-standing policy requiring parties to wait one-year from when CMS approved a WCMSA proposal to file an Amended Review request. In the big picture, this change will eliminate the delay in using the Amended Review process to seek a reduction in an approved WCMSA, which can help lower costs and facilitate settlement.

To help prepare for this change, the authors provide the following overview, including how Verisk’s Second Look service can help you leverage Amended Review to reduce WCMSAs:

1. What is CMS’s Amended Review process?

As a brief refresher, CMS implemented its Amended Review process in 2017. In general, Amended Review allows parties a one-time request to submit new medical documentation to adjust a prior WCMSA approval for cases meeting the Amended Review requirements.^[2]In a nutshell, this process allows parties to submit a new WCMSA proposal to CMS aimed at reducing a prior CMS WCMSA approval, which can help lower the WCMSA amount and help settle a claim. By eliminating the one-year waiting period, parties will no longer need to wait file an Amended Review request to seek a reduction in a prior approved WCMSA which, in turn, can help lower costs and facilitate settlement.

2. What is CMS’s Amended Review criteria?

CMS’s Amended Review criteria (with CMS’s forthcoming change noted) is as follows: “(i) CMS has issued a conditional approval/approved amount at least 12 months prior [NOTE: effective April 7, 2025, this one-year waiting period is eliminated]; (ii) the case has not yet settled as of the date of the request for re-review; and (iii) projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.”^[3]

If the above criteria is met, CMS “will permit a one-time request for re-review in the form of a submission of a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release information, and a summary of expected future care.”^[4]If CMS approves the Amended Review request, “the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased.”^[5]

3. How is CMS’s elimination of the one-year waiting period to file an Amended Review request helpful?

From the authors view, this decision by CMS is a helpful change to the Amended Review process. By eliminating the one-year delay in using the Amended Review process, parties now can quickly respond to an WCMSA counter-higher with new supporting documentation and mitigate additional costs while a claim remains open pending settlement.

4. Which claims may be ripe for Amended Review?

Determining which cases may be ideal for Amended Review is an important part of this process. In this regard, typical, and non-exhaustive examples, include situations where surgeries or procedures for implanted devices have occurred after the original WCMSA approval, the claimant’s treatment has stabilized or reduced, changes or reductions in medication have resulted in less monthly spend, and there has been a reduction in reserves over time. It is important to note, however, that CMS states that “the approval of a new generic version of a medication by the Food and Drug Administration does not constitute a reason to request an amended review for supposed changes in projected pricing.”^[6]

5. How can Verisk’s MSA Second Look help leverage Amended Review to reduce WCMSA costs?

In the big picture, CMS’s Amended Review can play an important role in reducing WCMSA allocations and getting claims back on the settlement track. With CMS’s new updates about to become effective, workers’ compensation insurers and other stakeholders should consider reviewing their claims inventory to see if they have any claims that would qualify for Amended Review, either on a case-by-case basis or perhaps as part of a targeted settlement project.

Toward this objective, keep in mind that Verisk’s MSA Second Look service can help you leverage CMS’s Amended Review process. In general, our consultative approach to MSA Second Look helps maximize the one chance you have at obtaining an Amended Review approval from CMS. As part of our process, we track changes in CMS pricing and medications, which may be helpful in reducing the WCMSA through an Amended Review request, and we carefully compare the prior WCMSA approval against the current changes in the claimant’s treatment to help determine if an Amended Review submission may be applicable. Overall, our MSA Second Look service has helped our customers achieve extraordinary WCMSA savings using the Amended Review process since CMS implemented the program back in 2017. For example, in 2024 alone, our MSA Second Look service delivered $4.4 million in client savings, with total client savings exceeding $55 million over the life of CMS’s Amended Review program.

Questions?

Please contact the authors with any questions regarding CMS’s Amended Review process or how Verisk’s MSA Second Look service can help you get claims settled.

[1] CMS announced this change as part of an Alert released in January 2025. In this Alert, CMS stated, in pertinent part, as follows: “Amended Reviews: Currently, amended review requests cannot be submitted until 1 year after a WCMSA case has been approved. Effective April 7, 2025, amended review requests will be allowed at any time after a WCMSA case is approved.” Id.

[2] WCMSA Reference Guide (Version 4.2, January 17, 2025), Chapter 16.3.

[3] Id.

[4] Id.

[5] Id.

[6] Id.