CMS releases updated Workers’ Compensation Medicare

November 16, 2022 / 4 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide (Version 3.8, November 14, 2022). This updated WCMSA Reference Guide (Version 3.8) replaces the Version 3.7 update dated June 6, 2022. Overall, CMS’s new updates add a new WCMSA re-review option and limit the number of re-review requests going forward.

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The following highlights key changes made in Version 3.8 of the WCMSA Reference Guide

CMS adds a new WCMSA re-review option

The new updates in Version 3.8 relate to WCMSA re-review requests. On this point, CMS describes the changes made in Section 1.1 of the Reference Guide as follows:

Clarification has been provided regarding re-review requests when errors exist in the submission documentation, as well as re-review limitations (Sections 16.1 and 16.2). Note: These re-review changes are only available for approvals from September 1, 2022 forward.

With this update, CMS has revised Section 16.1 of the WCMSA Reference Guide to add a new re-review option as follows:

Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2,500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward. Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document.

In terms of claims impact, for some time now, CMS has limited WCMSA re-review requests consider and adjust the value of a prior CMS approval amount to “Mathematical Errors” (previously known as “Obvious Mistakes”) and “Missing Documentation.” In July of 2017, CMS introduced the Amended Review request which supplemented CMS’s informal WCMSA re-review process by allowing submitters, albeit with certain restrictions, to provide new medical documentation to CMS to adjust a prior WCMSA approval.

Against this backdrop, with the introduction of the “Submission Error” option as part of the Version 3.8 updates, CMS appears to have expanded the WCMSA re-review process further by allowing the industry an additional opportunity to request a re-review. It remains to be seen how useful the “Submission Error” option will be to WCMSA submitters as the scope of potential use cases appears to be limited, especially when requiring a greater than $2,500.00 pricing change. However, given CMS’s historically limited re-review options, any expansion to the process will likely be welcomed by workers’ compensation insurers and practitioners.

CMS limits WCMSA re-review requests going forward

Another significant change with the release of Version 3.8 is CMS’s policy change to limit re-review requests.

The new 16.2 language now reads:

16.2 Re-Review Limitations

Note: The following re-review limitations are only available for approvals from September 1, 2022 forward.

Re-review shall be limited to no more than one request by type.

Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.

Re-Review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

From the claims perspective, through this new update CMS appears to further limit submitters to one re-review request by type. This is a significant limitation and policy change as CMS never previously limited the number of re-reviews that a submitter could request. In fact, submitters could and often had to make multiple re-review requests to highlight the WCRC contractor errors and obtain favorable WCMSA adjustments. In the bigger picture, this change could be viewed as another example of CMS leveraging the voluntary nature of the CMS submission process to move the goal posts, which results in further limiting oversight and adding additional challenges to the CMS submission process.

Conclusion

WCMSA Reference Guide Version 3.8 appears to present both positive and negative changes to the CMS submission process. While CMS granted the industry a new opportunity to leverage the WCMSA re-review process with the addition of the “Submission Error” option, it also limited the industry to one request per re-review option.

Verisk will monitor and test these changes as applicable going forward. We will also continue to look for opportunities to advocate positive changes and improvements to the WCMSA process. In the interim, because of the new re-review limitations, it is critical to make sure that the WCMSA submission packets and medical documentation are both accurate and complete.

Also, keep in mind that here at Verisk we apply a robust cost mitigation analysis to all the WCMSAs we complete and have been an industry leader for over a decade in helping clients reduce WCMSA costs through an array of different services. Through these services, combined with our advocacy driven approach, we have delivered results to help our customers save money and settle cases year after year. In 2021, we delivered over $158M in proactive WCSMA cost-mitigation; over $5M in CMS rebuttal savings; and over $13M in Amended Review savings. To learn more about our cost-mitigation options – including our new (and popular) Provider Outreach program – see our Verisk WCMSA Cost Mitigation Solutions.

Questions?

Please do not hesitate to contact the author if you have any questions.

CMS releases updated Workers’ Compensation Medicare Set-Aside Reference Guide (Version 3.8) – changes impact CMS’s WCMSA re-review process