A Solid Second Bite: CMS Re-review Now Allows New Medical Documentation

By Sidney Wong  |  July 11, 2017

Yesterday, the Centers for Medicare and Medicaid Services (CMS) released a new Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) User Guide and updated its re-review process to include a third option: re-reviews of WCMSA decisions based on significant treatment changes.

Prior Options Precluded CMS from Considering Current Changes in Treatment

CMS’ informal process had limited re-review of prior CMS decisions to these options:

  1. The original determination contained obvious mistakes
  2. Additional evidence is available that pre-dates the original submission

Those options didn’t allow submitters to obtain current dated medical documentation to clarify ambiguities after CMS issued a WCMSA decision.

The Terms of the New Third Option

Now, under “Amended Review,” CMS will consider current medical documentation that’s dated after the date of the original submission. A file will qualify if all these criteria are met:

  • The case was originally submitted to CMS one to four years from the current date.
  • There’s no prior request for Amended Review.
  • The current treatment has reduced or increased by at least 10% or $10,000.00 (whichever is greater) from the previous CMS-approved amount.

CMS indicates that for drug re-review requests to qualify under the third option, they must include more changes than merely substituting generic drug types for brand-name drugs.

Amended Review Is Straightforward, but Be Careful with the Threshold to Qualify

The CMS threshold criteria would mean that WCMSA approvals of $100K or less would use a $10K threshold and anything above $100K would use a 10% threshold to qualify for re-review. However, we confirmed that the CMS threshold example in the new WCMSAP manual is erroneous, so it’s currently unclear what CMS actually intends. “Third option” users must be careful until this is clarified and corrected. Remember, CMS is allowing only one submission for an Amended Review.

Still, the third option isn’t complicated:

  1. Enter a new WCMSA proposal amount.
  2. Submit treatment changes to medical services and drugs through the WCMSA portal.
  3. Upload supporting medical documentation.

Must the Claim Be “Not Settled”?

The original December 2016 CMS alert hinted that re-review process changes were aimed at files for which “settlement has not occurred.” However, with the new third option, there’s currently no reference or requirement to prove that’s the case. It may be that CMS will automatically disqualify an Amended Review if settlement documents are in the common working file or if a Total Payment Obligation to the Claimant (TPOC) date and amount is entered via Section 111 reporting. We’ll see.

The Change Grants Some Flexibility

The re-review process has been a frustrating way to resolve disputes about a WCMSA figure. From a claims handling perspective, it made little sense that CMS forced parties to use numbers that were outdated when compared with the current treatment course. While the Amended Review option doesn’t fix all the deficiencies of the re-review process, it grants some flexibility to correct or realign the WCMSA decision with a claimant’s current treatment. Hopefully, the third option will allow parties to revisit older files and put some claims to rest.

Contact ISO Claims Partners with any questions about WCMSAs and the re-review process.

Sidney Wong

Sidney Wong is the assistant vice president of policy at ISO Claims Partners, where he provides the highest level of client services—with a focus on meeting the needs of clients through ISO’s products and services. He is also responsible for assisting clients with effectively navigating Medicare compliance issues.