The Centers for Medicare and Medicaid Services (CMS) has released a revised Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide (Version 3.0, October 10, 2019). This guide replaces Version 2.9 of the guide which was released back in January 2019.
CMS lists its updates changes in Section 1.1. of the Guide. Significantly, as part of the new updates, CMS has expanded the time period for submitting Amended Review requests from four to six years. This change will provide parties with an expanded window to use new medical records, dated after the date of the original WCMSA submission, to change CMS’ WCMSA approval amount. Another significant change relates to the new consent to release form language requirements which become applicable in April 2020.
In addition, CMS has made updates to other areas including clarification on the methodology for pricing hospital fees for WCMSAs, an updated link to the current life table used to determine the adjusted life expectancy in WCMSAs, and additional guidance pertaining to WCMSA administration.
To help chart these amendments, the authors provide a general overview of the key WCMSA Reference Guide updates – including on how ISO CP can help you take advantage of the new expanded Amended Review process to reduce WCMSA costs – as follows:
Amended Review submission period expanded from four to six years
CMS has updated Section 16.2 of the guide to expand the eligible time period for submission of Amended Review requests from four (4) to six (6) years. ISO Claims Partners has checked the changes on the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) and can confirm that the new time frame is live on the portal.
By way of background, CMS introduced its Amended Review process in 2017. For qualifying cases, Amended Review can be used to amend the amount of a prior WCMSA decision by providing new medical records dated post-dating the date of the original WCMSA submission.
In Section 16.2 of WCMSA Reference Guide, CMS states the criteria for Amended Review as follows:
1. CMS will permit a one-time request for Amended review.
2. CMS has issued a conditional approval/approved amount at least 12, but no more than 72 months prior.
3. The case has not yet settled as of the date of the request for re-review.
4. 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.
Overall, this is a positive change since the initial restrictive qualifying time frame has been the primary obstacle for using the Amended Review. By extending the window to file an Amended Review by another two years, parties are given wider scope to settle older claims with significant changes in treatment. Arguably, since the Amended Review only allows a one-time request, it would be ideal if CMS, at some point down the line, removed the timeframe altogether. However, unless and until that happens, CMS’ extension of an additional two years is a welcomed improvement.
Services Note: Let ISO CP help you take advantage of CMS’ Amended Review option
ISO Claims Partners’ MSA Second Look service is tailored for the Amended Review process and has been quite successful in assisting parties in using the Amended Review option to lower the amount of a prior WCMSA approval.
To date, we have helped our clients reduce prior CMS approvals by an average of 53% and save over $12 million dollars through our MSA Second Look service.
With CMS now expanding the Amended Review submission window, we look forward to assisting you in using this option to challenge and lower prior WCMSA decisions to help settle out claims. Learn how our MSA Second Look can help you here.
CMS to add required language for the Consent to Release Form starting April 2020
Starting on April 1, 2020 CMS will require that claimants validate additional language in the CMS consent to release form indicating that he/she “understands the WCMSA intent, submission process, and associated administration.” (Section 10.2) In this regard, the new reference guide also provides an updated template with suggested language that complies with this new requirement. It is unknown at this time if this forthcoming change will present any challenges in terms of obtaining the claimant’s cooperation in securing the required consent forms.
Updated Life Table
CMS has updated the Life Table link in Section 10.3. to align with its recent use of the 2016 CDC Life Table to calculate adjusted life expectancies in WCMSAs.
Hospital Fee Schedules
In Section 9.4.3, CMS has clarified how hospital fee schedules are determined. Specifically, the Workers’ Compensation Review Contractor (WCRC) will price hospital fees based on “the Diagnosis-Related groups payment for the median Major Medical Center within the appropriate fee jurisdiction for the pricing ZIP code, unless otherwise defined by law.” This method for pricing hospital fees in WCMSAs has been in place for years, and the revised language in the WCMSA reference guide simply provides additional transparency around this pricing.
CMS updated Section 17.6 of the new guide to reflect that WCMSA administrators may now submit yearly and final attestations forms electronically through the WCMSAP. CMS also slightly tweaked the language under Section 19.2 addressing the handling of WCMSA funds should a claimant pass away with funds remaining in a WCMSA account. The language was updated to address the fact that the settlement language may dictate both the disbursal of funds and the settlement of care-related expenses. These updates are in line with recent changes CMS made to its WCMSAP User Guide and WCMSA Self-Administration Toolkit as more fully outlined in our prior articles.
On another front, in Section 17.3 CMS added new guidance and language indicating that it “expects that WCMSA funds be competently administered in accordance with all Medicare coverage guidelines, including but not limited to CMS’ Part D Drug Utilization Review (DUR) policy.” CMS goes on to state that “all WCMSA administration programs should institute Drug Management Programs (DMPs) for claimants at risk for abuse or misuse of “frequently abused drugs.”
With national focus on the impact of medication misuse and the opioid epidemic it is not surprising that CMS has decided to address the access of medications as part of the WCMSA administration process – especially in light of CMS’ practice of pricing WCMSA medications at present dosage and frequency over the claimant’s lifetime. What remains to be seen is if, how, and to what extent professional administrators will implement CMS’ guidance regarding this item; and if so, how such implementation will impact a claimant’s ability to use his or her WCMSA funds.
ISO Claims Partners will continue to monitor any impact from these changes and provide future updates as warranted. In the interim, please contact the authors if you have any questions.
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