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New version of WCMSA Reference Guide adds info on Re-Review process

November 21, 2022 · Medicare Insights Team

On November 14, 2022, The Centers for Medicare and Medicaid Services (CMS) released Version 3.8 of the Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) Reference Guide. Some of the changes/additions in this version pertain to the Re-Review process.

In Section 16.1, CMS added a third reason as a valid request for Re-Review to join the existing reasons of mathematical errors and missing documentation. The third valid request is noted as follows:

Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual.

Note: This submission option is only available for approvals from September 1, 2022, forward.

Examples include, but may not be limited to: medical records with incorrect patient identifying information; rated ages where the rated-age assessor provided incorrect information in the rated-age document.

With this new provision, CMS permits the request of an MSA correction in regards to documentation errors. This will allow re-reviews when rated-age related errors cause the rated age to be labeled invalid and the claimant’s “actual age” was used for the calculation of the Medicare Set Aside Allocation (MSA), potentially causing higher allocations.

Section 16.2 was also added and is titled Re-Review Limitations. The guide notates that this addition, as well as the addition above, are only available for approvals from September 1, 2022, forward. Section 16.2 states: Re-review shall be limited to no more than one request by type. Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error. Re-Review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

A newly added Section 16.2 is titled Re-Review Limitations and states: Re-review shall be limited to no more than one request by type. Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error. Re-Review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

Note: This addition, as well as the addition above, are only available for approvals from September 1, 2022, forward.

What both of these additions tell us is that CMS is clearly placing limitations on Re-Reviews, where in the past there were no set limitations on how many times you could request a re-review on the same matter.

CMS will be hosting a Section 111 Non-Group Health Plan (NGHP) reporting webinar on Tuesday, December 6, 2022, at 1:00 PM EST. The format will be opening remarks by CMS, a presentation that will include NGHP reporting best practices and reminders, followed by a question and answer session. For information regarding this webinar please click here: https://cms.zoomgov.com/j/1604816351?pwd=QmlUVUl1MkU4Y3htY1J0M0tUN3hoUT09

Optum Settlement Solutions will continue to keep the industry updated on all aspects of Medicare Secondary Payer (MSP) compliance, including issues pertaining to WCMSAs.