Success Spotlight: Persistence in the Re-Review Process Results in Savings of 65K
by K. Kline
Advancing customer interests through the effective use of the Centers for Medicare & Medicaid Services (CMS) re-review process continues to be an important part of IMPAXX’s Workers’ Compensation Medicare Set-Aside (WCMSA) customer service philosophy. If the decision is made to submit a WCMSA to CMS, it is important to closely scrutinize each CMS approval for possible errors. In June 2024, we shared an example of a successful WCMSA re-review based on missing documentation that resulted in a significant win for our customer, saving them $621,000.
Today we are highlighting another recent success achieved through effective use of the re-review process, which involved the improper inclusion of denied treatment in a WCMSA. CMS included psych treatment in an approval despite a timely denial and lack of any payment for treatment for that condition under the claim. Working closely with our customer, we discovered new documentation that predated submission and confirmed psych to be unrelated. CMS agreed to remove the denied treatment, saving the customer $18,400.
While this was a successful result, our analysis and re-review did not stop there. A close examination of the approval showed that CMS continued to include a sleep medication that medical records connected to psych issues, not orthopedic ones. As a result, IMPAXX flagged this as another possible error and initiated a second request for re-review. CMS again agreed with our assessment, returning a corrected approval that removed all denied treatment. The outcome? A total savings of $65,300 for the customer.
This case demonstrates the importance of thoroughly reviewing all approvals from CMS and obtaining the strongest support available for re-review. It also shows the importance of working with a WCMSA partner that understands the value of persistence. At IMPAXX, we remain committed to obtaining the lowest defensible WCMSA for our customers and advocating for consistent and accurate WCMSA results.
If you have any questions about the re-review process or would like to learn more about our innovative Medicare compliance solutions, please contact the IMPAXX Settlement Consulting team at [email protected].