Did you know that CMS has a new amended review process? Both parties can benefit from this option.
For example, what if the original MSA did not include a newly recommended and expensive procedure, or didn’t consider an admitted body part?
Or perhaps an expensive procedure, such as a spinal cord stimulator, was done prior to settlement, and no longer needs to be part of the MSA.
CMS will permit a one-time request for re-review when the following criteria are met:
- CMS has issued a conditional approval/approved amount.
- The case has not yet settled as of the date of the request for re-review.
- Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.
- In order to justify that the projected care would result in a 10% or $10,000 change (whichever is greater), the submitter must return CMS’ Recommendation Sheet that was included in CMS’ conditional approval letter and identify the following:
- Line items that were included in the approved amount, but are for care that has already been provided to the beneficiary.
- References to records indicating that the care has already been provided must be identified and easily located in the updated proposal.
- Line items for care that is no longer required with references to where replacement treatment can be found in the updated proposal.
- If additional care is required that was not otherwise included in CMS’ conditional approved amount, line items must be added.
- In order to justify that the projected care would result in a 10% or $10,000 change (whichever is greater), the submitter must return CMS’ Recommendation Sheet that was included in CMS’ conditional approval letter and identify the following:
- Additional documentation must be submitted:
- A new cover letter
- All medical documentation related to the settling injury(s)/body part(s) since the previous submission date
- The most recent six months of pharmacy records
- A new consent to release information
- A new summary of expected future care.
- In the event that treatment has changed due to a state-specific requirement, a life-care plan showing replacement treatment for denied treatments will be required if medical records do not indicate a change
- Requests for changes to treatment plans will not be accepted without supporting medical documentation.
Other things to note:
- The approval of a new generic version of a medication by the Food and Drug Administration does not constitute a reason to request an amended review for supposed changes in projected pricing.
- CMS will deny the request for re-review if submitters fail to provide the above-referenced justifications with the request for re-review. Submitters will not be permitted to supplement the request for re-review, nor will they be developed.
- When a re-review request is reviewed and approved by CMS, the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased.
We have the expertise to review your MSA and case files and determine whether or not an amended MSA review would be advantageous to your settlement goals.
Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement? Contact us for more information!
Our step-by-step process to get MSS working for you couldn’t be EASIER:
- Use our client portal at medicalsettlementspecialists.com to
complete a case intake form and upload documents. - On our intake form, tell us your settlement goals (for example, understand the medical exposure, help educate your client regarding their potential risks/benefits of settlement, review an MSA for accuracy, identify non-Medicare covered items, review contested body parts that may be related, etc.)
- Once you receive your draft report, schedule time to learn the best ways to utilize this powerful TOOL we have built for you!