CMS Announces Intent to Enhance Re-Review Process in 2017
Heather Sanderson
January 11, 2017

Yesterday, CMS issued an Alert which states the following (the alert can be found here):

The Centers for Medicare & Medicaid Services recently 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. In Calendar year 2017, CMS expects to update its existing re-review process 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 expects its updated process to address situations where certain states rely on Utilization Review Processes to justify proposed WCMSA amounts. Please continue to watch this site for more details in the coming months or subscribe for automatic notifications, see “Related Links” below.

Franco Signor Commentary: Recall back in February 2014 that CMS was looking to take similar action with regard to expanding its re-review process; however, CMS did not re-visit this thought until now. The proposed process back in 2014 sought to allow re-review for the following reasons: 1) A mathematical error was identified in the approved set-aside amount; 2) Original submission included case records for another beneficiary 3) Or Re-review requests could be submitted to the WCRC when the original WCMSA was approved within the last 180 days; the case has not settled; no prior re-review request has been submitted for this WCMSA; and, the re-review requests a change to the approved amount of 10% or $10,000 (whichever is more) for any of the following reasons:

  • Submitter disagrees with how the medical records were interpreted.
  • Medical records dated prior to the submission date were mistakenly omitted.
  • Items or services priced in the approved set-aside amount are no longer needed or there is a change in the beneficiary’s treatment plan.
  • A recommended drug should not be used because it may be harmful to the beneficiary.
  • Dispute of items priced for an unrelated body part.
  • Dispute of the rated age used to calculate life expectancy.

It remains to be seen whether CMS is looking to mimic their proposed process back in 2014. An expanded re-review process for WCMSAs are certainly desired by the industry, particularly for those cases that have not settled and medical treatment has drastically changed. With regard to Utilization Reviews, we are pleased that CMS is looking to take these into account where dictated as binding under state law. As CMS must look to state law when reviewing WCMSAs, this is a positive step.

2017 is looking to be an improved year for the WCMSA process. We will keep our readers updated.

 

Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP
Chief Legal Officer
Franco Signor LLC