CMS Expanded WCMSA Re-review Process

CMS Expanded WCMSA Re-review Process

So what do you do if you disagree with a decision from the Centers for Medicare & Medicaid Services (CMS) on a Workers’ Compensation Medicare Set Aside approval amount, or if the claimants treatment/Rx regimen has changed significantly since the original CMS approval of the WCMSA? Historically, parties to a settlement have always been able to submit a Reconsideration or Re-Review request. There are 2 scenarios where this is permitted:

  • Mathematical Error: if the CMS decision/approval contains obvious mathematical mistakes OR
  • Missing Documentation: if we have additional “evidence” not previously considered by CMS which was dated prior to the submission date of the original proposal which warrants a change in the proposal.

Expanded WCMSA Re-Review:

It has been about a year now since CMS really took a huge leap forward by expanding their Re-Review process. Parties to a settlement now have the ability to submit medical documentation that post-dates the original CMS approval – so long as it results in a 10% or $10,000 change in the allocation.

Originally set forth in V 2.7 of the WCMSA Reference Guide dated March 19, 2018 (and reiterated in subsequent versions), “where the following criteria are met CMS will allow a one time request for re-review in the form of a submission of a new cover letter, all medical documentation related to the settling injury/body part since the previous submission date, the most recent 6 months of pharmacy records, a consent to release information and a summary of expected future care.”

  • CMS has issued an approval at least 12 but no more than 48 months prior
  • The case has not settled as of the date of the Amended Review request
  • Projected care has changed such that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount
  • Must attach medical documentation that supports the MSA proposal resulting in the 10%/$10,000 change (this is the one instance wherein CMS will review/consider medical or legal documentation that post-dates CMS’ original allocation determination)

CMS has opened the door to a “2nd bite at the apple”. Not availing yourself to this new process may mean fewer settlements or potentially funding over-inflated WCMSA’s – negatively impacting your bottom line.


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