CMS announced yesterday that it expects to update its existing WCMSA re-review process. CMS indicated it plans to implement processes in calendar year 2017 to “address situations where CMS has provided an approved amount, but settlement has not occurred and the medical care that supported the approved amount has changed substantially.” CMS also stated it expects the updated process to address situations where certain states rely on Utilization Review Processes to justify proposed WCMSA amounts.
Based on the CMS alert, parties may consider a re-review WCMSA submission in cases where the following criteria are met:
- CMS has previously provided an approved WCMSA amount,
- Settlement has not occurred, and
- The medical care that supported the approved amount has changed substantially.
ExamWorks Clinical Solutions (ECS) will continue to assist clients with navigating this new and developing re-review process, and will keep you apprised of future CMS guidance to refine this updated process.
In the second half of 2016, ECS noticed CMS seemed to have relaxed its policy for WCMSA re-reviews in some instances. CMS now confirms such a change occurred by stating it “revisited the task of reviewing its process for addressing requests for CMS to ‘re-review’ otherwise approved Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts.” Prior to this alert, there existed no formal appeals process with respect to WCMSA approvals. The informal patchwork re-review process consisted of options to:
- Provide regional offices with additional documentation to justify proposed amounts;
- Correct obvious mistakes (mathematical errors or allocations for surgeries that have already occurred and need no revisions, etc.); and
- Provide additional evidence, not previously considered by CMS, which was dated prior to the submission date of the original proposal and which warrants a change in CMS’ determination.
As your trusted partner, over the years ECS advocated with others in the industry for changes to the re-review process, and ECS is encouraged to see CMS listened and is responding.
The Alert can be found here.