For the first time, parties involved in a Workers’ Compensation Medicare Set-Aside (WCMSA) can request a re-review of the MSA value when they dispute the CMS determination or when the financial circumstances of medical care vary from the approved MSA amount by ten percent or $10,000. In the past, insurers, corporations, and injured persons had only one opportunity to seek a re-review of the CMS MSA value determination by submitting a re-review request to the CMS Regional Office (RO) at the time of the settlement. If they remained unsatisfied with the CMS decision after that process, there was no other opportunity to seek an adjustment of what CMS determined to be the appropriate value of their MSA amount. For insurers and self-insured corporations, no further review meant they remained on the hook for the additional costs of care for work-related injuries, even when those costs were appropriately assignable to the MSA.

The newly released “re-review” opportunity, now titled an “Amended Review” allows all MSA constituents a new opportunity in which to argue that the costs of care for these injuries should shift to the MSA. The revised WCMSA Portal User Guide, version 5.1, released July 10, 2017, includes an “Amended Review” section at §12.4.3 that sets out the procedure and grounds for making an Amended Review request.

 

Two Reasons for an Amended Review

As of July 2017, WC case participants can seek an Amended Review if they disagree with the RO decision on the original settlement value, or if the projected cost of care has changed so significantly that the new proposed settlement amount totals more than ten percent or $10,000 from the original CMS approved amount. Only cases that have an approved status with the RO and have no other existing re-review requests pending can seek an Amended Review of the MSA value.

  • Disagreeing with the original MSA value determination

It is not unusual for the professionals involved in MSA cases to offer differing values for the claim. Both the insurance company or corporation and the CMS are obligated to keep their costs as low as possible, which means they must look for ways to reduce current and future costs of care for injured workers. Consequently, sometimes the net value of the MSA determination is insufficient to properly manage their injury or its long-term health consequences.

The new rules authorizing further review of a disputed MSA value allow MSA parties to submit additional information about the case and the projected costs of care to be considered within the original settlement discussions. Although how this actually affects MSA negotiations and agreements remains to be seen, the opportunity to seek another opinion about the future cost of care is most likely a boon to all involved.

  • Requesting a Revised (Amended) MSA Value

The option to review an existing MSA value is new to the CMS and arises from cases where the work-related injury worsens over time, requiring additional, unforeseen medical care costs. While many states permit reopening of WC cases if there is medical evidence that the injury has gotten significantly worse over time, those laws refer only to the original WC claim with the insurance company, and not to the resolution of the claim with CMS. Until this WCMSA Portal User Guide revision, MSA beneficiaries or their insurers had no opportunity to adjust the MSA value to reflect the long-term reality of the WC-related injuries.

 

Limitations on the Amended Review Process

Appropriately, the new WCMSA rules establish parameters that limit the timing and circumstances of Amended Review requests:

  • Submission of the original MSA settlement must have occurred between one and four years before the Amended Review request. For example, if the original MSA settlement date is July 1, 2015, then the period for requesting an Amended Review of its terms runs from July 1, 2016, through June 30, 2019.
  • An existing open Amended Review request prohibits a subsequent request.
  • The requested MSA value adjustment must be either (whichever is greater) ten percent more than the existing value or add at least $10,000 to the existing value. Medical and legal documents are required to prove the validity of the requested amount.

 

Workplace injuries impair both the life and future of injured workers and businesses and insurance companies work hard to be sure injured workers are well cared for through the term of the injury. MSA accounts are designed to cover the future medical costs of those injuries. The Amended Review process gives injured workers and those who support them the opportunity to seek an adjustment to the MSA account when its value doesn’t meet the needs of the medical case.

For more information about establishing or maintaining a Worker’s Compensation MSA, contact CompEx MSA today.