NQBP Alert! CMS’ Proposed expansion of the WCMSA Re-Review Process

NQBP Alert! CMS’ Proposed expansion of the WCMSA Re-Review Process

On February 11, 2014, CMS released a proposed expansion of the WCMSA re-review process with comment period open until March 31, 2014.

Currently CMS’ re-review process is limited and can be used if one of the following has occurred:

1. CMS’ determination contains obvious mistakes (e.g. mathematical error or failure to recognize medical records already submitted showing a surgery, priced by CMS, that has already occurred
2.  You believe you have additional evidence, not previously considered by CMS, which was dated prior to the submission date of the original proposal and which warrants a change in CMS’ determination

The proposed expansion would expand on the process for a broader array of reasons.

Original WCMSA was approved within the last 180 days, the case has not settled; no prior re-review request has been submitted for this WCMSA; and, the review requests a change to the approved amount of 10% or $10,000 (whichever is more) for any of the following reasons:

1. Submitter disagrees with how the medical records were interpreted
2.  Medical records dated prior to the submission date were mistakenly omitted
3.  Items or services priced in the approved set-aside amount are no longer needed or there is a change in the beneficiary’s treatment plan
4.  A recommended drug should not be used because it may be harmful to the beneficiary
5.  Dispute of items priced for an unrelated body part
6.  Dispute of the rated age used to calculate life expectancy

Click here to read the full proposed expansion.