The Centers for Medicare and Medicaid Services (CMS) announced on February 11th that it is seeking comments on the manner in which CMS plans to expand the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) re-review process. See : http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/Downloads/WCMSA-Re-review-Expansion.pdf.  Currently, CMS has a limited re-review process for WCMSA amounts that can be used in situations where CMS is notified that the submitter omitted documentation from the original proposal or when a mathematical error was made by Medicare’s review contractor.

Below is a summary of the proposed expanded re-review process. CMS is asking for comments on all aspects of the proposal, including comments on the timeframe, threshold and reasons for granting a re-review. Once the process is finalized, CMS will post implementation dates and detailed instructions on how to use this process on the WCMSA website. Comments or concerns with the proposed process should be sent to WCMSARereview@cms.hhs.gov  by March 31, 2014.

Under the planned expanded process, re-reviews will be available for a broader array of categories and reasons. All requests for re-review will be sent to the Workers’ Compensation Review Contractor (WCRC) for resolution within 30 business days. The WCRC will direct the request to a group of experts best skilled to review the identified issue. The experts that perform the re-review will not be the same specialists involved in the original determination.

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.

In certain situations, a re-review may be elevated by the WCRC to a CMS Regional Office. This level of review will occur in situations such as, failure to adhere to court findings; CMS policy disputes; carrier maintains Ongoing Responsibility for Medicals for treatment that has been included in approved WCMSA, etc.

CMS will schedule a Town Hall Teleconference prior to implementation of the expanded re-review process.

We believe that CMS is responding to numerous concerns expressed by submitters about the lack of a responsive and timely review or appeals process for many issues that have arisen and in response legislation (HR 1982) which would establish an appeals process for WC MSA reviews.

UWC will be filing comments in response to this notice from CMS. If you have particular issues that need to be addressed in re-reviews and/or concerns about the timeframes and finality of the process, I will include them in UWC comments to be filed.