A Second Bite at the Apple?

CMS Expands the WCMSA Re-Review Process

Do you have cases that you cannot settle due to an outdated, CMS-approved WCMSA?  If so, there is good news – CMS has expanded its WCMSA Re-Review process, which allows for resubmission of those old CMS-approved WCMSAs in certain situations.

Section 12.4 of the most recent version of the WCMSAP User Guide (Version 5.1, dated July 10, 2017) provides a new opportunity for WCMSAs to be re-reviewed where parties believe projected care has changed so much that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in the amount previously recommended by CMS.  This new exception to the existing re-review process will now be identified as the “Amended Review” option.  The requirements for the newly permitted Amended Review are:

1. The WCMSA must have been originally submitted between one and four years from the date of the request for Amended Review; and

2. An Amended Review for the WCMSA at issue has not already been requested (there is only one Amended Review allowed per WCMSA); and

3. The requested change must result in the greater of a 10% or $10,000 change in the previously approved amount.  Please note the parties may request that the WCMSA recommendation be increased or decreased by 10% / $10,000, whichever is greater.

The addition of the Amended Review did not alter the existing re-review options, which permit a re-review request where the parties believed CMS’ determination contained obvious mistakes (mathematical errors), or where the parties obtained additional evidence, not previously considered by CMS, which was available prior to the date of the submission of the original WCMSA proposal.

We encourage you to take advantage of this expanded process and consider whether you have any old CMS-approved WCMSA cases that are outdated and meet the criteria for Amended Review.  Please contact Hedrick Gardner’s Medicare Secondary Payer Practice Group if you would like to discuss the Amended Review option in greater detail, and see how it applies to some of your challenging cases!