The Centers for Medicare & Medicaid Services (CMS) issued an updated Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide on July 31st. There are several important changes.

This guide was written to help readers understand the process used by the Centers for Medicare & Medicaid Services (CMS) for approving proposed Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts and to serve as a reference for those choosing to submit such amounts to CMS for approval. Submitters may include injured workers themselves, their attorneys, Workers’ Compensation Medicare Set-Aside Arrangement (MSA) agents or consultants, or claimants’ other appointed representatives.

Under the provisions of the new Guide, CMS has expanded the criteria for submission of a WCMSA re-review, which is the closest thing it has to an “appeal” of a prior CMS MSA valuation.

Effective 07/31/2017, submitters can submit a re-review request where CMS has provided an approved amount, but settlement has not occurred and the medical care that supported the approved amount has changed substantially. The clarifications also address situations where certain states rely on Utilization Review processes to justify proposed WCMSA amounts.

Re-review functions as the only “appeal” type process to the amount CMS requires to approve a submitted WCMCA with a settlement.

Previously there were two Re-Review options (1 and 2 noted below). Now, CMS adds a third option referred to as the “Amended Review”.

– Option 1: You believe CMS’ determination contains obvious mistakes
– Option 2: You believe you have additional evidence, not previously considered by CMS, which was available prior to the submission date of the original proposal which warrants a change in the CMS’ determination.
– Amended Review: You believe projected care has changed so much the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

CMS specifies only one Amended Review is permitted per case and another re-review cannot be requested if a request for an Amended Review is denied. The following criteria have to be met for a case to be eligible for an Amended Review:

– The case must have been originally submitted between one and four years from the current date and cannot have a previous request for an Amended Review
– Must result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount

CMS has also noted as part of the re-review request, you may change from brand-named medications to generic medications and drug types. However, this change cannot be the sole reason for your re-review request. You must include additional changes (such as changes in dosage and/or frequency, additional medications, or medications no longer taken) to qualify for a re-review request.

Carriers and Third Party Administrators now have an opportunity to evaluate open cases to verify if any would fit the criteria for an Amended Review if medical circumstances have changed since CMS submission. The new criteria may provide a chance to settle the case where previously it was not possible.