Verisk Analytics Inc.
01/23/2025 | Press release | Distributed by Public on 01/23/2025 14:45
CMS will end one-year waiting period to file WCMSA Amended Review requests
In a major development on the workers' compensation Medicare set-aside (WCMSA) front, the Centers for Medicare and Medicaid Services (CMS) has released an Alert advising that effective April 7, 2025, Amended Review requests "will be allowed at any time a WCMSA case is approved." Accordingly, this forthcoming change will eliminate the current one-year waiting period to file an Amended Review request.
As a brief refresher, CMS implemented its Amended Review process in 2017. In general, Amended Review allows parties a one-time request to submit new medical documentation to adjust a prior WCMSA approval for cases meeting the Amended Review requirements.[1] In a nutshell, this process gives the parties a second bite at the apple (so to speak) to reduce a prior CMS WCMSA approval in certain circumstances which can help lower the WCMSA amount and help settle a claim. Overall, this change will likely be received favorably by many workers' compensation stakeholders as it will eliminate the delay in using the Amended Review process to seek a reduction in an approved WCMSA which can help lower costs and facilitate settlement.
In preparation for this upcoming change, the authors outline the following:
CMS's current Amended Review criteria
CMS's current Amended Review criteria is as follows: "(i) CMS has issued a conditional approval/approved amount at least 12 months prior; (ii) the case has not yet settled as of the date of the request for re-review; and (iii) 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."[2] If this criterion is met, CMS states that it "will permit a one-time request for re-review in the form of a submission of a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release information, and a summary of expected future care."[3] If CMS approves the Amended Review request, "the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased."[4]
In terms of which claims may be ideal for consideration for an Amended Review, typical, and non-exhaustive, examples include situations where surgeries or procedures for implanted devices have occurred after the original WCMSA approval, the claimant's treatment has stabilized or reduced, changes or reductions in medication have resulted in less monthly spend, and there has been a reduction in reserves over time. It is important to note, however, that CMS states that "the approval of a new generic version of a medication by the Food and Drug Administration does not constitute a reason to request an amended review for supposed changes in projected pricing."[5]
Starting April 7, 2025, an Amended Review request will be allowed at any time after a WCMSA case is approved
Regarding the above criteria, CMS will terminate the current 12 month waiting period to file an Amended Review submission starting April 7, 2025. In this regard, CMS states that "[e]ffective April 7, 2025, amended review requests will be allowed at any time after a WCMSA case is approved."[6] This means that parties will no longer have to wait one-year to file an Amended Review submission. From the authors view, this decision by CMS is a helpful change to the Amended Review process. By eliminating the one-year delay in using the Amended Review process, settling parties now have the opportunity to quickly respond to a MSA counter-higher with new supporting documentation and mitigate additional costs while a claim remains open pending settlement.
Verisk's MSA Second Look leverages Amended Review to reduce WCMSA costs
In the big picture, CMS's Amended Review can play an important role in reducing WCMSA allocations and getting claims back on the settlement track. In preparation for CMS's upcoming change, workers' compensation insurers and other stakeholders should consider reviewing their claims inventory to see if they have any claims that would qualify for Amended Review either on a case-by-case basis, or perhaps as part of a targeted settlement project.
In this regard, Verisk's MSA Second Look service can help you optimize CMS's Amended Review process. In general, our consultative approach to MSA Second Look helps maximize the one chance you have at obtaining an Amended Review approval from CMS. As part of our process, we track changes in CMS pricing and medications which may be helpful in reducing the WCMSA through an Amended Review request, and we carefully compare the prior WCMSA approval against the current changes in the claimant's treatment to help determine if an Amended Review submission may be applicable.
Overall, our MSA Second Look service has helped our customers achieve extraordinary WCMSA savings using the Amended Review process since CMS implemented the program back in 2017. For example, in 2024 alone our MSA Second Look service delivered $4.4 M in client savings, with total client savings exceeding $55 over the life of CMS's Amended Review program.
Questions?
Please do not hesitate to contact the authors if you have any questions or would like to learn more about how Verisk's Second Look can help you take advantage of CMS's Amended Review process to reduce costs.
[1]WCMSA Reference Guide (Version 4.2, January 17, 2025), Chapter 16.3.
[2] WCMSA Reference Guide (Version 4.2, January 17, 2025), Chapter 16.3.
[3] WCMSA Reference Guide (Version 4.2, January 17, 2025), Chapter 16.3.
[4] WCMSA Reference Guide (Version 4.2, January 17, 2025), Chapter 16.3.
[5] WCMSA Reference Guide (Version 4.2, January 17, 2025), Chapter 16.3.