13 Feb 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
- 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.