By Patricia Kent, Medicare Secondary Payer Compliance Counsel
CMS’ new “Amended Review” process has been in place for a year. Amended Review allows parties to – in certain select circumstances – obtain a second shot at the Medicare Set-Aside approval. This new process is separate from the “standard” Medicare Set-Aside reconsideration process. Let’s take a look.
What is Amended Review and how does it work?
Under Amended Review, parties are able to consider a re-review of a CMS approved MSA amount via an Amended Review under the following criteria:
- CMS previously provided an approved WCMSA amount between 1-4 years prior to the date of the Amended Review request;
- Settlement has not occurred; and
- Medical care that supported the CMS approved amount has changed substantially, resulting in a 10% or $10,000 (whichever is greater) difference from the approved amount.
How is Amended Review different from the standard “Reconsideration” process?
CMS has always authorized reconsideration of Medicare Set-Aside evaluations whenever Medicare’s contractor made an “obvious error.” This limited reconsideration process is still available to ask CMS to re-review an approved amount upon discovery of a mathematical error and or some other item that may have been missed or misinterpreted by Medicare the first time around.
While a reconsideration letter is something that can be narrowly interpreted – and occasionally tailored to fit into the “obvious error” standard – the Amended Review standard is clear cut. Simply stated, if the dates and amount in controversy align, and if the case has not settled, CMS will allow the second shot. If the case falls outside of those ranges, the parties are left to navigate the reconsideration criteria.
What are some considerations for the Amended Review cases?
Amended Review is particularly useful in cases where the case has not settled, and a prior adverse MSA decision was holding up the settlement. It’s also useful where settlement hasn’t occurred yet but Medicare’s original MSA amount would be quite a bit different due to the subsequent changes in treatment patterns.
Once you have determined that Amended Review may be right, keep in mind that there is only one chance at Amended Review. If information is missing or inaccurate, Medicare can reject the Amended Review request out of hand. So, a word to the wise: get your dominoes in a row before you attempt an Amended Review.
Of what other items should you be mindful?
ExamWorks Clinical Solutions submitted a substantial number of successful Amended Reviews during the first year of the new process. Here are the top three things to think of when attempting Amended Review:
- Follow the rules. While CMS may issue a request for minor information and not reject an Amended Review request, CMS is strictly adhering to “one and done” for submission of an Amended Review. That means there is only one chance to provide evidence that the medical care is now either 10% or $10,000 (whichever is greater) different from CMS’ approved amount and that between one and four years has passed since the original approval by CMS. You also need to make sure that the only change is not related to prescription drug pricing.
- Leave no stone unturned. Medicare will not hold a prior unfavorable reconsideration attempt against you. If the reconsideration effort fails shortly after a CMS counter-higher, it may be worth it to wait until a year has passed and give Amended Review a try. Just be sure that you have all of your dominoes in a row so you can be sure to survive Medicare’s checklist of requirements.
- Don’t be shy. We have seen some tremendous changes from CMS’ original determination letter to the approved Amended Review determination. The original recommended MSA may have come in very high but regardless of the original MSA amount Medicare will approve often substantially lower Amended Review amounts if the current treatment patterns and recent injury history suggest that the claimant’s condition has stabilized and more cost-effective treatment is pursued. Often times the Amended Review result is several hundred thousand dollars less than the original MSA.
As your trusted partner, ExamWorks Clinical Solutions will continue to monitor the new Amended Review process. If you have a case that has not settled after CMS approval of an MSA, please contact your local ExamWorks Clinical Solutions account executive or Patricia Kent at email@example.com. We can discuss Amended Review for your case and assist you in repositioning that case for settlement.
About Patricia Kent
Patricia Kent is Medicare Secondary Payer Compliance Counsel at ExamWorks Clinical Solutions. Patricia worked as a Registered Nurse for 20 years, and has specialized in MSP compliance for the last decade. Patricia is a frequent lecturer and has been recognized in the Federal Courts as an expert witness in the area of Medicare Secondary Payer compliance. She is a member of the Florida Bar. She graduated from Stetson College of Law with a JD. Patricia can be reached at 678-256-5048 or firstname.lastname@example.org.