Are You Taking Advantage of CMS’ New Amended Review Thresholds?

Various blue charts, some of which are on a clipboard with a pen, calculator, and magnifying glass on top of it.

by M. Heberling

We recently noted in our blog that the Centers for Medicare & Medicaid Services (CMS) issued the newest version of the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) User Guide version 3.9. As far as updates to the User Guide go, the latest installment was relatively action-packed with new information that could affect the direction of your claim. This includes updates to the Amended Review guidelines, clarification on the implantation intervals for intrathecal pain pumps and spinal cord stimulators, and changes to the processes of the Workers’ Compensation Review Contractor (WCRC) and the CMS regional offices.

Reviewing Updates to the Amended Review Guidelines

For purposes of this post, we are specifically highlighting the updated Amended Review guidelines. Previously, CMS restricted the time during which you can pursue an Amended Review to between one and six years after the time of approval. Thus, CMS offered only a five-year window, starting one year after their initial approval, in which you could submit information for them to take a “fresh look” at the file and provide a new approval amount.  In WCMSA User Guide version 3.9, CMS removed the maximum time limit of six years. There is now an indefinite period (which still starts one year after the approval date) to pursue an Amended Review.

We previously indicated that the Amended Review changes are welcome news for parties who were unable to avail themselves of the process due to the six-year limit. Those parties were left with less optimal choices, such as settling only indemnity and leaving medical open, settling future medical using an old CMS approval amount, or settling using a new MSA that cannot be submitted for review and dealing with the specter of future challenges by CMS. They may also have submitted for an Amended Review despite the timing not being ideal because they would otherwise lose the opportunity. Fortunately, parties will no longer have their backs against the wall when making these types of decisions.

Saving Settlement Dollars: An Amended Review Example

Given updates to the Amended Review guidelines, it is an excellent time to assess older claims, with a CMS approval, that continue to have open medical and have not been able to settle. With older claim files, it is very possible that the outlook for future medical has changed. For instance, a surgery included in a CMS approval may have since occurred, a new medication or generic may have become available and be in use, or a previously implanted medical device (like a spinal cord stimulator) may have been removed. These scenarios could all theoretically result in major reductions to future medical costs, but evidence for such may previously have been precluded from CMS’ review due to the Amended Review time limit.

As an example of how Amended Reviews can save you settlement dollars, we recently performed an Amended Review Analysis for a customer and found changes to the prescription regimen since the prior CMS approval. The changes were such that the file would qualify for Amended Review and presumably result in substantial reductions to the approval amount. The customer was approaching the six-year limit and opted to submit the file for an Amended Review. CMS performed their review and issued a new determination that lowered the approval amount by about $87,000. Had this file been examined several months later, the customer would have lost the opportunity to better position the file for settlement. So, it should bring some peace of mind knowing the time limit has been removed and there is no longer a deadline for managing a claim.

Determining If Your Claim Qualifies for an Amended Review

The IMPAXX team can work with you to conduct a complimentary Amended Review Analysis to determine whether your claim qualifies for an Amended Review under the new guidelines and assess whether the timing is right to submit it to CMS. It is important to remember that even without a six-year time limit the Amended Review remains a one-time request. My hope is that, in the future, CMS will continue to change their guidelines in a way that benefits our customers, such as allowing Amended Reviews to be submitted more than once.

For questions regarding updates to the WCMSA guide, or for more information about our Amended Review analysis and settlement services, please contact our Settlement Consulting team at [email protected].