CMS re-review

Greg Gitter Offers Thoughts on CMS Re-Review Policy

Our very own Greg Gitter was recently interviewed as part of an article by our good friends at WorkCompCentral regarding some of the positive and negative effects of the Medicare Set Aside (MSA) re-review policy set forth by the Centers for Medicare and Medicaid Services two years ago.

 In 2017, CMS opened the door for a one-time re-review of an MSA provided the revised approval would result in a change to the MSA of at least 10% or $10,000, whichever was greater. Prior to this policy, CMS would only review and approve an MSA one time which could often leave settlement parties with no recourse if the approved MSA figure did not line up with the terms of their agreement.  In those instances, a decision was typically made to leave the file open and no longer pursue a settlement.  

 This policy change has been met with mixed results from our vantage point here at Legacy Claim Solutions. We often see instances where there have been drastic changes in treatment and medications subsequent to a CMS approval.  Previously those changes were irrelevant as the CMS approval was set in stone, however there is now an opportunity to position a file for a re-review which can re-open the door to negotiations and settlements, and we have had success with this process.  However, as the article states, parties must keep in mind the timeframe allowed for the one-time re-review.  In addition to the dollar or percentage requirement, an existing MSA approval must be between 12 and 48 months old to qualify.  Unfortunately, this stipulation eliminates many older files from the re-review consideration even though the treatment has changed dramatically.  We would like to see the timeframe requirement expanded to give these older MSAs an opportunity to be updated with current medical and prescription needs.  This would undoubtedly open the door to settlements on older cases that had been written off years ago.

 Overall, however, this has been a welcome change to the stale review policy that had been in place for years.  It is evident that CMS wants to work with the settlement community to improve the Medicare Secondary Payer compliance system when changes are needed.  We applaud the National Alliance of Medicare Set Aside Professionals (NAMSAP) for continuing their efforts to serve as the voice of the MSA industry.

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