On 2/11/2014, CMS issued an important request for comment to expand WCMSA Re-Review Process. Today, the WCMSA Re-Review process is limited to situations where: 1) CMS has notified the submitter of missing documentation; or 2) A mathematical error was made by Medicare’s review contractor of the WCMSA. These limited situations have proved less than adequate for most situations where obvious errors could be easily corrected. CMS recognizes this and under the planned expanded re-review process shall also include:
- Re-review at any time for the following situations; or
- A mathematical error identified in the approved set-aside amount; or
- Original submission included case records for another beneficiary
- Re-review within 180 days of the WCMSA approval when:
- The case has not settled:
- No prior re-review has been submitted for the WCMSA; and
- Change in approved amount is the greater of 10% or $10,000 of the WCMSA and for either 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; or
- Dispute of rated age used to calculate life expectancy.
It is important to note that under the planned expansion of the re-review process the Medicare review contractor (WCRC) will re-reviewand resolve within 30 business days. More importantly, the panel that will conduct the re-review will not be the same specialists involved in the original determination.
Another aspect of this request for comment is that it is not a regulation comment request because the present WCMSA process is voluntary. Therefore, it is not to be confused as Advanced Notice for Proposed Rule Making (ANPRM) or a Notice for Proposed Rule Making (NPRM) or similar regulatory process to develop regulations. This is a simple request for comment that is due directly to CMS by March 31, 2014. To submit comments about the proposed expansion, or other reasons for granting a re-review, please send them in no later than the above date to the following email address: WCMSARereview@cms.hhs.gov.
Franco Signor will be submitting our own comments, and if you would like to have yours included with ours, please send them directly to email@example.com prior to March 31, 2014. To help prepare your comments, here are some concerns we identified which is not an exhaustive list:
- Should state law limitations be specifically referenced?
- What about generic drugs?
- Is the 180 day period too limiting?
- What about medications that become disapproved by Medicare after approval of the MSA?
We are continuing to monitor and look forward to hearing your thoughts about this important change.