CMS Delivers Expanded Re-Review Process and Modifies Case Re-Opening Process

CMS issued an updated Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) User Guide, Version 5.1 on July 10, 2017. Section 12.4 of the Guide outlines the new expanded Re-Review process for CMS approved cases , as promised by CMS in its December 21, 2016 Alert. Under this Section, a party may now seek a re-review when the current care projections differ by 10% or $10,000, whichever is greater, from the projections in the CMS determination. The difference may be higher or lower.

In order to seek an “Amended Review”, the following requirements must be met:

  • The original submission must have occurred between one and four years before the date of the Amended Review request.
  • Cannot have a prior request for an Amended Review.
  • The change in treatment must result in the greater of either a 10% or $10,000 change in the prior CMS determination amount.

The portal process for completing the Amended Re-Review request requires a line by line review of the CMS determination projections along with the entry of the new treatment projections and reference to specific supporting documentation. Since parties are still able to seek a re-review when they disagree with the CMS determination, this right will presumably apply to the Amended Review determination.

The updated Guide also revised the case re-opening process for submissions that have been closed by CMS. Section 12.3.5 provides that parties will have to resubmit the entire case, along with all associated documentation, when more than 12 months have passed since the date of the last closeout letter. This is essentially a new CMS submission in the case.
NuQuest offers the “Amended Review Submission Service” upon request. Our Service Coordinators and Settlement Consultants will also work with you to determine the optimal approach for your case. Although the CMS “Amended Review” is a welcome addition, the NuShield Certified MSA may be a better option.

CMS Announces Update To Re-review Process in 2017

CMS issued an announcement on December 21, 2016 stating that it expects to update its re-review process in 2017. CMS expects the re-review to address situations involving open claims with CMS determinations where the post CMS review medical care has changed substantially. CMS also expects to update its process to take into account situations where state law allows reliance on the Utilization Review Process to support the future care in the claim. More details will be provided in the future by CMS.

This announcement signals a welcome shift from CMS’ prior posture that limited WCMSA review to a one-time event. It would also appear that the substantial change in the approved amount of the medical care may apply to both increases and decreases. Whether this shift will expand to a willingness to return to the procedure followed in April 2003/ July 2005 when a beneficiary was allowed to petition for a reduction/ termination of a WCMSA amount given a substantial improvement in the beneficiary’s medical condition remains to be seen. This procedure had been rescinded in August of 2008. CMS’ updated re-review process should also take into account the need for both parties to be involved in the decision to seek a re-review.

CMS’ acknowledgement of the role that utilization review may play in a state is also long overdue. A more uniform application of the utilization review decisions to the future care projections by CMS will provide a greater focus on state law in determining the WCMSA.

We will keep you advised of further developments.

CMS Announces Town Hall Teleconference

On November 17, 2016, CMS will host a teleconference to discuss the following:

Ongoing responsibility for medicals (ORM) recovery
Final Conditional Payment process reminders
Medicare Secondary Payer Recover Portal (MSPRP) improvements

CMS will respond to questions submitted to the email address: COBR-NGHP-Comments@cms.hhs.gov

Date: November 17, 2016
Call in time: 1:00PM to 2:30 PM EST
Number: 800-603-1774
Passcode: 987659

CMS asks that all callers be dialing in 5-10 minutes before the call start time.

A Look at the NGHP Conditional Payment Recovery Transition to the Commercial Repayment Center

The Centers for Medicare and Medicaid Services (CMS) transitioned a portion of their Non-Group Health Plan (NGHP) conditional payment recovery work to the Commercial Repayment Center (CRC) as of October 5, 2015. The Benefits Coordination and Recovery Center (BCRC) remained responsible for the conditional payment recovery involving NGHPs in actions that were initiated prior to October 5, 2015. The transition to the CRC occurred several months after CMS implemented a direct right of appeal for conditional payment recovery actions directed towards an “applicable plan”. The direct right of appeal, mandated by the SMART Act, was effective as of April 28, 2015.

The transition of the NGHP conditional payment recovery work to the CRC has been less than smooth at times. Although CMS’ October 5, 2015 Alert regarding the transition to the CRC noted it was intended to improve claims payment accuracy in MSP situations, the CRC has been plagued with:

  • data migration errors
  • workflow process breakdowns
  • miscommunication of file information to clients
  • extreme delays in processing conditional payment notifications
  • conditional payment notices that include multiple charges unrelated to the reported injury
  • appeals to these erroneous charges being denied without a formal review
  • final demands being generated when disputes are pending review and determination

The ripple effect of the struggling contractor’s problems has been felt by many in the MSP community. These issues and possible solutions have been the subject of numerous recent discussions between the NuQuest team and the CRC management team. In discussions with the CRC, we were advised that:

  • The overly broad conditional payment notices were due to an error in their Tier 2 filter setting. This has since been corrected, and all new conditional payment notices will be given an additional review by CRC’s quality control analysts.
  • Conditional payment notices and demands that have already been sent should be disputed through the direct appeal process. We have been assured that going forward; CRC’s review of the disputes will be thorough.

We will continue in our efforts to resolve issues with the CRC by meeting with them regularly and will keep you posted.