Amended Review and Other Takeaways from the Latest WCMSA Reference Guide

By Kate Riordan and Sidney Wong August 1, 2017

On July 31st 2017, the Centers for Medicare and Medicaid Services (CMS) released its most recent version of the Workers’ Compensation Medicare Set-Aside Reference Guide—and there’s a lot to digest. We received some clarification about how CMS will implement the new “Amended Review” option we wrote about previously. CMS also provided “clarifications” and changes for hearings on the merits and state-specific statutes, spinal cord stimulator pricing, and a host of other topics. While a more comprehensive analysis will shortly follow this post, here’s what we know now.

No Second Chance at Amended Review

When CMS expanded the re-review options to include an Amended Review, it allowed parties to request review of all current medical documentation and evidence—even if it postdates the date of the original submission. From the recent release, we learned that (1) settled claims are ineligible for Amended Review requests, (2) the CMS recommendation sheet must be included in the request, and (3) CMS will not develop for missing information. So, to qualify for Amended Review, a file must show that the case:

  1. has not yet settled as of the date of the request for re-review
  2. was originally submitted to CMS between one and four years from the current date
  3. has no prior request for an Amended Review, and
  4. involves treatment with a reduction or increase of at least 10% or $10,000 (whichever is greater) from the previous CMS-approved WCMSA amount

What We Still Don’t Know about Amended Review

Unfortunately, CMS failed to clarify how reviewers are treating the 10% or $10,000 threshold, so parties should still err on the side of using the higher amount rather than relying on the example in the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) manual.

More Changes in Version 2.6 of the WCMSA Reference Guide

Please stay tuned as we further dissect these announced changes:

  • Further clarifying expectations of hearings on the merits (Section 4.1.4)
  • Updating defined requirements for spinal cord stimulator pricing (Section 9.4.5)
  • Correcting BCRC contact numbers from previous versions
  • Expanding state-specific statute guidelines (Section 9.4.5)
  • Clarifying total settlement calculations guidelines (Section 10.5.3)
  • Adding ICD-10 examples to sample cover letter
  • Clarifying jurisdictional verification (Section 9.4.4, Step 5)
  • Clarifying change of submitter requirements (Sections 9.0, 10.2, and 19.4)
  • Updating re-review policy (Section 16.0)
  • Adding required resubmission requirements (Section 16.1)
  • Updating administration recommendations (Section 17.1)
  • Adding MyMedicare.gov link (Section 17.6)
  • Updating off-label medication requirements (Section 9.4.6.2)

We’ll soon analyze all the impacts of the new reference guide’s requirements for submitting WCMSAs to CMS for review and approval. Meanwhile, for answers to questions about the recent updates to the WMCSA reference guide, please reach out to Sidney Wong at Sidney.Wong@verisk.com.


Kate Riordan and Sidney Wong

Kate Riordan is the director of Medicare Secondary Payer (MSP) initiatives at ISO Claims Partners. She has well over five years of experience in completing Medicare Set-Asides and obtaining CMS approvals, with a concentration in California claims. Kate graduated Bowdoin College and Suffolk University Law School and is a Medicare Set-Aside Certified Consultant. 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.