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CMS Alert—Beneficial Changes Expected For CMS Re-review Process

CMS recently issued an alert stating that it expects to expand the existing WCMSA re-review process. This potential expansion will include situations in which CMS has provided an approved amount, but settlement has not occurred and the medical care that supported the approved amount has substantially changed.

According to current CMS policy, a re-review is appropriate in the following situations: (1) you believe CMS’ determination contains obvious mistakes; (2) you can provide additional documentation that justifies the original proposed amount; or (3) you have additional evidence, dated prior to the date of the original submission, that warrants a change in CMS’ determination.

Noticeably absent from that list of options is the situation where CMS has provided an approved amount and the claimant’s medical care changed substantially prior to settlement. Fortunately, according to the recent CMS alert, it appears that CMS has revisited its policy on re-review in that situation and is expected to make changes concerning the same in the coming year. This would be a very welcome, positive change that we have been encouraging CMS to explore for quite some time.

We are anxiously awaiting its implementation, as it will provide a direct and potentially invaluable benefit to our clients. As always, we will monitor this expansion closely and will keep you apprised of any new developments.

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