Proposed Expansion of WCMSA Re-Review Process

 

CMS has announced they are looking for comments and feedback regarding their proposed expansion of the WCMSA Re-Review Process.  Their proposed Re-Review Process has two(2) components:

 I. Re-review requests can be submitted at any time to the WCRC for the following reasons:

  • A mathematical error was identified in the approved set-aside amount.
  • Original submission included case records for another beneficiary.

II. Re-review requests can 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.

We believe this is a positive step in the right direction for our industry.  However, we do have some concerns about the specific language:

  • A 10% or $10,000 threshold is too high
  • Re-reviews only allowed for cases “not settled” – does this mean re-reviews are not allowed if the
    settlement was already approved – or does this include cases that have been
    tentatively settled without yet receiving judge’s approval (the majority of
    submissions)?
  • No prior Re-review request submitted – this implies we would have only one shot at the re-review process, even if we still disagreed.

More to come on this important development.  To view the full text of the proposal, please click on the link below.

http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/Downloads/WCMSA-Re-review-Expansion.pdf

 

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