On May 15, 2023, the Centers for Medicare & Medicaid Services (CMS) updated its Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide. This version (v3.9) contains several updates (as outlined in Sec. 1.1), but the most notable update, relative to the Amended Review process, is addressed in this article.
Amended Review Eligibility Time Limit Eliminated
With the Amended Review process, in the instance of a previously approved Medicare Set Aside (MSA), CMS allows for the one-time re-review so long as:
- CMS has issued a conditional approval/approved amount at least 12 months prior;
- the underlying case has not yet settled as of the date of the request for re-review; and
- the projected care has changed to the extent that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) than CMS’ previously approved amount
In regard to the timeframe for the Amended Review process, with the new Reference Guide, CMS has eliminated the time limit – which was previously 6 years. Of note, there is still a “waiting period” of at least 12 months (from the date of approval) prior to engaging in the Amended Review process. See Sec. 16.3 for additional clarification and requirements pertaining to the Amended Review Process. Please note the Amended Review Process is separate and distinct from the Re-Review process (see sections 16.1 & 16.2).
Amended Review: Increased Opportunities for Settlement
CMS extended the Amended Review process to 6 years in October of 2019 with version 3.0 of the Reference Guide. With this change in v3.9, the time limit has been eliminated altogether. This opens opportunities for parties to avail themselves to the Amended Review process that could lead to settlement where they otherwise would have been unable to because of the time restriction.
It will be critical for claims payers to conduct file reviews to determine what claims may now be eligible for review. It is important to note that the claim must not have settled, and the new proposed amount would result in a 10% or $10k change from the original CMS determined amount.
For claims where a previously approved amount may have been prohibitive for settlement and it is beyond 6 years from the CMS decision, there are now opportunities for analysis around areas such as:
- determining if medical and prescription utilization has changed or if surgeries occurred or are now recommended
- obtaining an updated MSA
- deploying cost-mitigation strategies
- conducting a cost-benefit analysis relative to settlement vs. leaving medicals open
- approaching the claimant relative to settlement
We applaud CMS for removing the time-limitation on the Amended Review process and Ametros is available to assist payers, TPAs, and attorneys in evaluating older claims with prior MSA approvals for settlement opportunities. If you have any questions regarding CMS' update to the time limit elimination of the Amended review process, please contact Ametros or John Kane AIC, CMSP-F & MSCC, VP of Strategy directly.
