CMS Workers’ Compensation Medicare Set-Aside Arrangement Re-Review Procedures
On July 10, 2017, the Centers for Medicare & Medicaid Services (“CMS”) released the Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide to assist in understanding the procedures for using CMS to approve Workers’ Compensation Medicare Set-Aside Arrangements (“MSA”). While CMS does not have a formal appeals process for people who disagree with CMS’s assessment of the MSA, the reference guide included three procedures for a re-review that may be helpful to practitioners.
Mathematical Error
CMS will re-review the MSA if it contains an obvious mistake, such as a mathematical error or a failure to recognize medical records already submitted showing treatment that has already occurred, such as a surgery. It is important to note that the medical records must have already been submitted.
Missing Documentation
CMS will re-review the MSA if the submitter/claimant has additional evidence not considered by CMS that is dated prior to the submission date and justifies a change in CMS’s determination.
If we break this down into its component parts, the missing documentation re-review requires:
- Additional evidence;
- Not considered by CMS;
- Dated prior to the submissions date;
- Justifies a change in CMS’s determination.
If subsequent evidence comes in, CMS allows for a one-time re-review as indicated below.
Amended Review
CMS allows for a one-time re-review that includes submitting a new cover letter, all medical documentation related to the settled body parts since the previous submission, six months of the most recent pharmacy records, a signed consent to release information, and a summary of expected future care. This amended review is subject to:
- CMS issuing a conditional approval amount at least 12 months but no more than 48 months prior to the resubmission,
- The case not settling as of the date of the re-review request, and
- The projected MSA resulting in a change of $10,000.00 or 10%, whichever is more.
This 10% or $10,000.00 change is justified by returning CMS’s recommendation sheet and identifying:
- Items that were approved and already provided,
- Items that are no longer necessary, and
- Additional care that is required but was not included in CMS’s conditional approval amount.
If your CMS conditional approval was more than 48 months prior to the re-submission, it is possible that CMS will continue to extend the period to include older approvals, on a case by case basis.
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