For years, the Centers for Medicare and Medicaid Services (CMS) has refused to consider medical evidence postdating the original submission date of a Workers’ Compensation Medicare Set-Aside (WCMSA) proposal. This refusal has been one of the more frustrating aspects of the WCMSA review process. In far too many instances, CMS has blocked review of subsequent treatment updates and other information that could lower the approved WCMSA allocation amount. This policy has long been criticized as being unfair, resulting in inaccurate WCMSA allocations and preventing claims settlement.
Now, there is finally some good news. This past summer, CMS introduced its new “Amended Review” process through which parties may now submit new medical evidence—postdating the original WCMSA submission date—for CMS evaluation. If understood and applied correctly, the new process could help lower WCMSA allocations and breathe new life into stalled settlements.
This welcomed development—and how we can help—is broken down as follows:
CMS' Amended Review Process
Historically, CMS has limited the basis for re-review of WCMSA approvals and determinations to two options: one for obvious mistakes (for example, mathematical errors, inclusion of unrelated conditions, etc.) and the other for evaluation of medical records predating the WCMSA submission date that were not included in the original submission package. These two options remain available and can be helpful in challenging WCMSA determinations in their applicable (and limited) contexts.
Now, there is a third re-review option: Amended Review. This new option expands CMS’ existing re-review process by allowing consideration of new medical evidence postdating the original WCMSA submission date in certain circumstances.
The main requirements for the CMS Amended Review process include:
- CMS has issued a conditional approval/approved WCMSA amount at least 12 but no more than 48 months prior to filing of an Amended Review request.
- The case has not yet settled as of the date of the request for re-review.
- Projected care has changed to the extent that the new proposed WCMSA amount would result in a 10% or $10,000 change (whichever is greater) to CMS’ previously approved amount.
- Where a re-review request is reviewed and approved by CMS, the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased.
In addition to the above, it should be noted the Amended Review process can be used only once—and a submitted request that does not qualify for the process still counts toward this one-time rule. So, parties must be confident that their request qualifies. Further, Amended Review requests involving prescription drugs must be based on something other than simply switching the drug from brand to generic.
Taking Advantage of Amended Review
In the big picture, the CMS Amended Review process provides an unprecedented opportunity to use new medical evidence to seek reductions in prior CMS WCMSA approvals in unsettled claims. Now is a good time for claims payers to evaluate their current claims inventory and determine which cases may benefit from the new process. An evaluation should include looking at cases with WCMSA decisions dated within one to four years of a proposed Amended Review request and which did not settle due to CMS’ approved WCMSA amount being too high.
Triggers for review include high single-cost-driver services (such as spinal cord stimulators), recommended treatment that did not occur or occurred after the WCMSA was submitted, high-cost prescriptions, durable medical equipment, and prescription weaning. All strategies for cost mitigation should be considered at this time.
How We Can Help: MSA Second Look
For more than a decade, we have successfully used CMS’ re-review options to challenge and reduce high WCMSA approval amounts. In 2016, we secured more than $8 million in WCMSA re-review savings for our customers—and we are on target to surpass that figure in 2017.
We are now proud to add MSA Second Look to our lineup. This new service is specifically designed to help you optimize WCMSA savings from CMS’ Amended Review process.
Key features of our MSA Second Look service include:
- full review and analysis of all medical records dated after the original WCMSA submission
- in-depth comparison between the current medical treatment and the WCMSA determination
- an analysis of whether the claim qualifies for the Amended Review process
- a road map for additional proactive intervention to reduce costs
- consultation with our experienced medical and legal team
Our MSA Second Look service is already achieving very positive results for our customers. We look forward to helping you realize similar savings. Because you can only take one bite out of the Amended Review apple, let our team help you get it right in navigating CMS’ intricate Amended Review process.