CMS Issues New WCMSA Reference Guide Version 3.8

By B. Smith

Yesterday, CMS released version 3.8 of their Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide, which now includes an additional Re-Review option when the parties wish to dispute the amount of a WCMSA proposal. The IMPAXX team was expecting this addition since CMS spoke about the new option at the 2022 National Medicare Secondary Payer Network Annual Conference in September.

While CMS does not have a formal Workers’ Compensation Medicare Set-Aside (WCMSA) appeals process, options were provided over time for disputes through their Re-Review and Amended Review processes. Traditionally, the Re-Review process included two (2) ways parties could request a new WCMSA amount. The first occurred when the WCMSA contains mistakes such as a mathematical error or a failure to recognize (through review of medical records) that treatment had already taken place. The second occurred when the parties provided additional evidence dated prior to submission that would warrant a change in the CMS determination. CMS also recently limited re-review requests if no change was made to the WCMSA after review.

With the release of version 3.8, CMS has now included a third option in Section 16.1 for re-review requests based upon submitter error. This addition provides as follows:

3. Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward.

      • Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document

CMS also added the following Re-Review Limitations to Section 16.2:

Note: The following re-review limitations are only available for approvals from September 1, 2022 forward.

Re-review shall be limited to no more than one request by type.

Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.

Re-Review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

Key takeaways from the above include the following:

    • The new Re-Review option is only available for WCMSA approvals from September 1, 2022 and ongoing.
    • To qualify for this option, the pricing change with the corrected information must be $2,500 or greater.
    • Re-Reviews are limited to one type per case (i.e., one mathematical, one missing documentation error or one submission error).
    • The documents submitted for re-review must be submitted error free.
    • The documents in error must come from the originator with a notation that the error was corrected, the date of the correction, and a hand-written “wet” signature from the originator.

If you have any questions regarding the latest WCMSA Reference Guide, or need assistance with WCMSA submissions, Re-Reviews, or Section 111 Reporting, please do not hesitate to contact the Settlement Consultant Team at [email protected].