A Comprehensive View of the Amended Review Process

Recap of Amended Review:

It has been four years since CMS introduced its Amended Review process on July 10, 2017. By way of background, Amended Review finally afforded the parties with an opportunity for a second bite of the apple following the issuance of a CMS decision. Qualifying cases for Amended Review must provide a revised MSA supported by updated documentation (e.g. medical records, pharmacy history) and meet the following criteria:

  1. CMS approval is dated 1-6 years prior;
  2. Case has not settled; and,
  3. A significant change in treatment resulted in a 10% or $10,000 (whichever is greater) change in CMS’ approved amount.

In Version 2.6 of the July 31, 2017 WCMSA Reference Guide, CMS provided information for the new process. That included the above criteria (CMS originally required the approval dated 1-4 years prior) and limited guidance surrounding the process: Amended Review is a one-time opportunity for each case and after submission of the Amended Review, the file may not be supplemented – creating a “one and done” submission.

What We Have Learned in the Last 4 Years:

Question: Can a change in a medication from Brand to Generic be a consideration for Amended Review?

Answer: A change in a medication from Brand to Generic may not be the sole reason for the Amended Review. However, such a change can be included in the revised MSA in connection with other significant treatment adjustments.

Question: Does CMS consider updated information such as changes in the claimant’s life expectancy, and/or rated age and State Fee Schedules for Amended Review?

Answer: Yes, the Amended Review should update the life expectancy and/or rated age of the claimant, which will generally lower the MSA amount. CMS also updates the applicable State Fee Schedule on its review, which may increase or lower the MSA.

Question: One of the claimant’s conditions have resolved. Will CMS exclude that condition in the Amended Review?

Answer: Yes, CMS will exclude documented resolved conditions in Amended Review. However, be aware that the Reviewer will carefully examine all submitted documents. If the documents evidence a resolved condition, but also a new condition related to the Workers’ Compensation date of injury, that new condition will be included.

Question: The treating physician has now discontinued Claimant’s opioids. Can that be a basis for Amended Review?

Answer: If the documentation evidences discontinuation of Claimant’s opioids (or other medications) and the cost of those medications meet the 10% or $10,000 (whichever is greater) criteria, CMS will exclude the opioids and the urine drug screens. This generally will result in a substantial savings.

Question: Can I include additional body parts/conditions related to the claim to the Amended Review?

Answer: Yes, CMS accepts additional body parts/conditions related to the claim in the Amended Review. The Reviewer will include future medicals for the additions, and exclude any duplicative treatment in the MSA.

ExamWorks Compliance Solutions carefully monitors CMS’ Amended Review process. If you have a case that has not settled after CMS approval, please contact us for an evaluation of your file for Amended Review.

Patricia Strang

Patricia Strang

Patricia Strang joined ECS in 2011 as a Medicare Secondary Payer (MSP) Compliance Counsel. In this role, Patricia combines her extensive medical and legal backgrounds to help guide ECS’ clients through the MSP and ECS’ compliance services. Prior to joining ECS, Patricia had a private practice, which included litigating Personal Injury and Medical Malpractice cases. She is admitted to practice law in Florida and holds a Florida nursing license. Patricia is a graduate of Stetson College of Law.

Patricia can be reached at patricia.strang@examworkscompliance.com or at 678-256-5048.