CMS Announces New Guidelines For Re-Review Of Previously Approved WCMSAs

In the WCMSA User Guide version 5.1 which was published on July 10, 2017, CMS finally expanded the circumstances under which they will consider a re-review of a previously approved WCMSA. Prior to the recent change in the User Guide CMS would only consider a re-review where:

1: The individual requesting re-review believed CMS’ determination contained obvious mistakes (e.g., a mathematical error or failure to recognize Medical records already submitted showing a surgery, priced by CMS, that has already occurred).
OR
2: The individual requesting re-review believed he/she has additional evidence, not previously considered by CMS, which was dated prior to the submission date of the original proposal which warrants a change in CMS’ determination.

Section 12.4 of the latest version of the User Guide now provides a third scenario where CMS will consider re-review of a previously approved WCMSA. This section states:

3: When you disagree with the Regional Office (RO) decision on a case, or if projected care for a case has changed so much that the new proposed settlement amount differs from CMS’ approved amount by 10% or $10,000 (whichever is greater), you can submit a re-review request. A WCMSAP case is eligible for re-review if it is in approved status at a Regional Office and a re-review is not already in process.

To be eligible for an Amended Review, the case:

• Must have been originally submitted between one and four years from the current date;
• 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.

The following example is given in the Guide for how 10% change is calculated:

• An approved Medicare Set-Aside (MSA) is $80,000. Since $10,000 is greater than
$8,000 (which is 10% of the approved MSA), then $10,000 will be used in calculation.

• The New Proposed MSA Amount is $88,000. Since $8,000 ($88,000 – $80,000) is at least a 10% change, this amount is eligible for an amended review. Note: The New Proposed MSA Amount can be greater than or less than the Approved MSA Amount, as long as the difference is at least 10% or $10,000 (whichever is greater).

Since the re-review must be requested through the WCMSAP “portal”, it appears that the re-review request must come from the original submitter. If you would like more information on whether your case qualifies for re-review, please feel free to contact me at (866) 306-9423 or glisowski@msaservicesllc.com.

Gregory F. Lisowski, JD MSCC