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MS updated its Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide on November 14, 2022. The new Reference Guide Version 3.8 provides an additional basis for re-review in Section 16.1., as well as limitations for re-review in a new Section 16.2.
As you may recall, CMS has no formal appeal process if the parties disagree with the Determination Letter. However, there have been very limited re-review (aka Reconsideration) criteria in place for some time now. In the past, CMS has only entertained re-review for so- called “obvious errors” mathematical errors by the reviewer or for mistakenly omitted documents, which must pre-date the submission date.
In Section 16.1 CMS added the following basis for re-review available for approvals from September 1, 2022 forward:
Submission Error: “Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2,500, a re-review request may be made by submitting updated documents free of errors that cased 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 that hand-written “wet” signature of the correcting individual.” Examples provided include “…medical records with incorrect patient identifying information or where the rated-age assessor provided incorrect information in the rated-age document.”
This is a significant step forward by CMS, allowing the correction of good faith mistakes post-submission, especially those often created by computer-generated medical records.
Re-Review Limitations: Next with the addition of Section 16.2, CMS now restricts re-reviews to “no more than one request by type.” Presumably, this means that there may only be one re-review submitted per mathematical error, missing documentation and submission error. Previously, there was no limit to the number of re-reviews filed. It appears that CMS is now mirroring their “one and done” Amended Review criteria for re-reviews.
Section 16. 2 also requires a reference to a specific document if the re-review alleges a failure to properly review submitted documents. Finally, CMS indicates that “disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.” Overall, we are pleased that CMS has agreed to formally expand the re-review process. It is also understandable that CMS has added some limitations to the process, no doubt to streamline and lighten its WCRC workload, and to avoid situations where submitters made attempt after attempt to get the preferred result.
ExamWorks Compliance Solutions continuously monitors regulatory and legislative developments in the Medicare Secondary Payer space. For further information about this Report or if you have any questions, contact Patricia Strang at 678-256-5048.
