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 This procedure had been rescinded in August of 2008.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.