Amended Review: No More Waiting in Line

The Centers for Medicare and Medicaid Services (CMS) recently announced changes to the Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) review process concerning Amended Reviews via an industry-wide alert.[1]? This change is welcome to many industry stakeholders and will hopefully allow quicker settlements to a backlogged workers’ compensation system.

??????????? What is “Amended Review?”

The Amended Review process is found in Section 16.3 – Amended Review of the WCMSA Reference Guide.? Under existing policy, Amended Review is allowed only once provided the following conditions are met:

• CMS has issued a conditional approval/approved amount at least 12 months prior;
• The case has not yet been settled as of the date of the request for re-review; and
• Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount; and

Where a re-review request is reviewed and approved by CMS, the new approved amount will take effect on the settlement date, regardless of whether the amount increased or decreased.

The amended review is a new submission – a second chance to receive a lower CMS-approved MSA amount.? The barrier for many in undertaking this process is the 12-month waiting period, which many argued was cumbersome and delayed settlements.

??????????? What Will Happen in April?

Effective April 7, 2025, CMS will no longer require submitters to wait to submit an Amended Review.? Instead, “amended review requests will be allowed at any time after a WCMSA case is approved.”[2]

This is a welcome change to the WCMSA process and will assist all interested stakeholders in moving workers’ compensation cases forward.? It remains to be seen if there will be an influx in Amended Review submissions, or delays in initial MSA submissions.

??????????? Next Steps:? Approaching the New Amended Review Process

Interested stakeholders should continue to be proactive in their compliance practices regarding Medicare Secondary Payer issues and the voluntary WCMSA review and approval process.? The following steps can be taken to avoid delay if there is a consideration of using the Amended Review process:

• Proceed with caution using Amended Review.? CMS can increase its initial MSA amount upon review of the new submission.? There are no guarantees of a lower amount upon receiving approval;
• Maintain a complete set of medical and pharmacy records.? CMS will likely scrutinize the dates of the first and last records received as part of the Amended Review process.? Avoid the possibility of Development while in Amended Review;
• Communicate with all parties to a settlement if the MSA will be submitted for Amended Review; and
• Know the requirements of the Amended Review process as it is governed by CMS policy.? This is a one-time chance to receive a better (or worse) determination.

Always work with a Medicare Secondary Payer service provider with a passion driven by results.? Constantly review and evaluate your case and make better decisions about submitting a case through the voluntary WCMSA review and approval process. Communicate with all interested stakeholders and set proper expectations to avoid settlement delays.

DISCLAIMER: This document aims to identify and discuss issues in an educational manner and is not intended to constitute legal advice as to any particular claim or situation. ?Always consult your attorney as to specific situations.?The views and observations expressed in this article are solely those of the?author and are not endorsed in any way by any other sponsors, firms, corporations, entities, or government agencies.?

[1] CMS – Workers’ Compensation Medicare set aside arrangements – What’s New – January 25, 2021; https://www.cms.gov/medicare/coordination-benefits-recovery/workers-comp-set-aside-arrangements/whats-new

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[2] Id.