CMS Allows Insurers A Second Chance With Their Medicare Set Aside Submissions

On July 10, 2017 The Centers for Medicare and Medicaid Services (“CMS”) published a new Workers’ Compensation Medicare-Set Aside Portal (“WCMSAP”) User Guide and updated its policy regarding reconsideration of unfavorable Medicare Set-Aside (“MSA”) determinations.

Previously CMS allowed for a very limited re-review process, reserved for situations where either: 1) CMS’ determination contained an obvious mistake, such as a mathematical error; or 2) to review additional medical evidence dated prior to the date of the original CMS submission which warranted a change in CMS’ determination.

In December of last year CMS announced that it expected to update its’ existing re-review process. In the newly released WCMSAP, CMS confirmed that, in addition to an obvious error or the existence of evidence dated prior to the original submission, it would also accept an “Amended Review” when the submitter believes that “projected care has changed so much that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.”  This change allows the parties to submit recent medical information to CMS to indicate why the MSA amount approved by CMS does not properly reflect the conditions in the claim.

Based upon the new CMS policy, parties can now request a re-review of a prior MSA submission in the following circumstances:

1) CMS’ determination contained an obvious mistake, such as a mathematical error; or

2) to review additional medical evidence dated prior to the date of the original CMS submission which warranted a change in CMS’ determination.

In December of last year CMS announced that it expected to update its’ existing re-review process. In the newly released WCMSAP, CMS confirmed that, in addition to an obvious error or the existence of evidence dated prior to the original submission, it would also accept an “Amended Review” when the submitter believes that “projected care has changed so much that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.”  This change allows the parties to submit recent medical information to CMS to indicate why the MSA amount approved by CMS does not properly reflect the conditions in the claim.

Re-Reviews can be requested either via the WCMSA Portal or by submitting a request to WCMSA Proposal/Final Settlement, P.O. Box 138899, Oklahoma City, OK, 73113-8899.

A link to the most recent WCMSAP user guide can be found here: http://bit.ly/2A4jviN 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s