The Wait is Over: CMS Change to Amended Review Timing Begins in April

By M. Heberling

April will bring impactful changes to the Centers for Medicare & Medicaid Services (CMS) review process. We wanted to highlight these changes and make sure your organization is prepared to navigate the shifting landscape.

Changes Coming in April

In a recent blog post, we discussed the upcoming changes to the Amended Review timeline that will take effect in April. CMS indicated that as of April 7, 2025, and moving forward, Amended Reviews may be requested any time after a Workers’ Compensation Medicare Set Aside Arrangements (WCMSA) approval is issued by CMS. While the guidelines for an Amended Review remain the same, parties no longer need wait an entire year after WCMSA approval to submit an Amended Review request.

Frustrations with Current Policy

The existing policy created significant frustration in the industry because of the potential for causing delays in settling claims. Organizations that receive a CMS approval that is seemingly too high, and incongruent with current treatment patterns, generally want to seek new physician opinions and medical records to “fix” the CMS approval amount immediately. However, since CMS will only review documents that pre-date the WCMSA submission, requesting a Re-Review in these situations is not a viable option. Rather, parties needed wait a full year for an Amended Review to become available, which increased claim costs. As such, eliminating the one-year requirement may lead to lower claim costs.

Proceed with Caution

However, there are, a few points of caution. First, an Amended Review remains a one-time request and just because you can request an Amended Review immediately after receiving a WCMSA approval, does not mean that you necessarily should.

You want a high level of predictability in the outcome of CMS’ Amended Review. Therefore, you should confirm you have all office visit records, optimal opinions from all treating physicians, and any relevant Court Orders that fully support the changes you are seeking. After all, you want to present your case in the best possible light at the time of submission. In addition, you still need meet the Amended Review guidelines, which includes a change of 10 percent or 10,000 in the WCMSA amount to support the review. Understanding these guidelines is imperative to prevent the complete denial of your Amended Review request.

Awaiting Clarification from CMS

You should also be aware that CMS has not fully clarified whether these changes apply to all CMS approvals. The assumption is currently being made that changes to Amended Review timing are both retrospective AND prospective. However, CMS has not specifically indicated whether these changes apply to all CMS approvals or only approvals that occur after April 7, 2025. We have requested clarification and are awaiting a response from CMS. Regardless, in anticipation of this change, we recommend that you review any high-dollar CMS approvals and start working on mitigation strategies for costly items with new medical reports and other relevant supporting documentation.

IMPAXX’s Settlement Consulting team has significant experience with the Amended Review process and can help you determine whether newly obtained documentation supports a predictable, beneficial result. Our team can also assist with claim reviews and work with you to develop mitigation strategies, and help you identify cases that are the best fit for Amended Review.

For more information about our Amended Review analysis and settlement services, please contact our Settlement Consulting team at [email protected].