Pursuant to Section 16.0 of the Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide, Version 2.8, October 1, 2018, COBR-Q4-2018-v2.8, CMS will conduct a Re-Review of a prior WCMSA determination in certain circumstances. Specifically, CMS will complete this process in cases involving a mistake in the allocation; mathematical error; or when there is missing documentation that pre-dated the WCMSA submission date that could change its value. CMS will also perform an Amended Review when there are changes to the WCMSA that post-date CMS approval and the case meets certain criteria. Knowing when and how to use the appropriate Re-Review process is imperative in helping to prevent inaccurate or over-inflated WCMSAs.
One recent example of NuQuest successfully utilizing the appropriate Re-Review option involved an appellate court order that was issued after the date of the WCMSA submission. The case involved whether claimant required ongoing treatment for a work-related lumbar spine injury. The appellate court determined that the description of injury was an aggravation of a lumbar sprain and claimant’s intervening injuries as well as a gap in treatment evidenced that claimant’s work injury had resolved. Highlighting the timeline of the appellate process; the court’s rationale; medical evidence; and the nature of injury, NuQuest was able to successfully advocate for a zero dollar WCMSA. This resulted in over an $18,000 savings to the client.
Critical review of a WCMSA to determine if a Re-Review is warranted is a necessary part of the Medicare compliance process. However, identifying these issues is only one part of the equation. Knowing the appropriate arguments to include in a Re-Review as well as the appropriate mechanism to make this request is equally important to obtain a successful result.
For further information regarding WCMSAs or any Medicare compliance needs, please contact the NuQuest Legal Team.