As you may be aware, on July 10th, here on our blog we announced the quiet release of a change to CMS’ re-review process.  However, as we noted at that time, this process was not formalized by CMS, and had simply been released through CMS’ Workers’ Compensation Medicare Set-Aside Portal (WCMSAP).  Specifically, through a revised WCMSAP User Guide, which can be found here.

As we cautioned on July 10, CMS typically will issue a formal announcement regarding a new process prior to the process actually being implemented by CMS. CMS has finally released a formal announcement regarding the new re-review process, an “Amended Review,” through a revised WCMSA Reference Guide, which can be found here.  CMS has deemed the new re-review option available and effective as of July 31, 2017.  As we previously indicated, in order to exercise the amended re-review option, the following criteria must be met:

  • The MSA must have been originally submitted between one and four years from the date the re-review is submitted (meaning that very recently approved cases are not eligible for this re-review process);
  • The re-review request cannot have had a previous request for an Amended Review; and
  • Must result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

The Amended Review is a welcomed expansion to the re-review process, allowing for changes in care to be accounted for by CMS for cases which have not settled.

Within the revised WCMSA reference guide, CMS also:
  • Further clarified expectations of Hearings on the Merits (Section 4.1.4);
  • Updated defined requirements for Spinal Cord Stimulator pricing with CPT coding (Section 9.4.5);
  • Corrected BCRC contact numbers from previous versions;
  • Expanded state-specific statute guidelines (Section 9.4.5);
  • Clarified total settlement calculations guidelines (Section 10.5.3);
  • Added ICD-10 examples to the Sample Cover Letter found in the guide;
  • Clarified jurisdictional verification (Section 9.4.4, Step 5);
  • Clarified change of submitter requirements (Sections 9.0, 10.2, and 19.4);
  • Added required resubmission requirements (Section 16.1);
  • Updated administration recommendations (Section 17.1);
  • Added link (Section 17.6); and
  • Updated Off Label Medication requirements (Section

Interestingly, within the guide, CMS clarified that it will now recognize state specific statutes addressing limitation on future treatment.  This is particularly important for those jurisdictions, which have a jurisdictional statutory cap such that funding an MSA over a claimant’s entire lifetime would be limited.  Historically, such limitations have not been honored by CMS; that is, until now.

As we previously advised, CMS also added required resubmission requirements. This is a requirement, for those cases where a case has been closed for over a year due to lack of information where a closeout letter has been issued.  These cases will need to be resubmitted as when submitting a new MSA submission; including documentation for the past two years.

Another interesting addition to the revised WCMSA reference guide is the inclusion of the following by CMS: “Although beneficiaries may act as their own administrators, it is highly recommended that settlement recipients consider the use of a professional administrator for their funds.”  This makes us wonder whether annual attestation forms may be scrutinized more heavily in the coming months.

We are happy to see that CMS has finally issued a formal announcement regarding the new re-review process, making it now effective.  We are also pleased to see clarification regarding the jurisdictional limitations cap, which we have been advocating for, for quite some time.  If you have questions regarding CMS’ voluntary submission program, submitting a case for an amended re-review, or general MSP compliance, we are here and happy to assist you.  Please send your questions to [email protected].