CMS Removes 1 Year Waiting Period for Amended Reviews; Upcoming Sanderson Firm Webinar
Written by: Brendon De Souza
A prior version of this blog article incorrectly referenced July 17, 2025 as the effective date. Please note that CMS’ Amended Review policy change becomes effective April 7, 2025.
In more sweeping policy changes from The Centers for Medicare & Medicaid Services (CMS) to kick off the new year, CMS announced yesterday that Amended Review requests will be permitted at any time after CMS returns a Workers’ Compensation Medicare Set-Aside (WCMSA) determination effective April 7, 2025.
Amended Review is one of two recognized administrative remedies[1] allowing parties who have already received a CMS determination on a submitted WCMSA proposal to request that CMS modify its previous determination amount. Typically, Amended Review is sought in instances where parties believe that CMS should have approved a lower WCMSA amount.
CMS currently permits Amended Review when the following criteria are met:
· CMS has issued a conditional approval/approved amount at least 12 months prior*
o To be eliminated on April 7, 2025
· The case has not yet settled as of the date of the request for Amended 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
Beginning on April 7, 2025, parties to a workers’ compensation settlement will no longer be required to wait 12 months from the date of CMS’ determination letter to request an Amended Review. This impending policy change marks the second time in two years where CMS has eliminated an Amended Review deadline — in the winter of 2023, CMS removed the restriction which barred parties from requesting an Amended Review if it was requested more than 72 months from the date of CMS’ determination letter. CMS has not yet updated the WCMSA Reference Guide reflecting its Amended Review policy change, but we expect CMS will do so on or before April 7, 2025.
Given all of the recent CMS activity regarding WCMSA policy changes (i.e., upcoming removal of 12 month waiting period for Amended Review requests, upcoming elimination of zero WCMSA reviews, upcoming WCMSA Section 111 reporting requirements, etc.) as well as popular interest in civil money penalty exposure for improper Section 111 reporting practices, Sanderson Firm is excited to host an upcoming webinar on February 4th from 1:30 PM – 2:30 PM EST titled, New Year, New Changes to MSA Processes and Section 111 Civil Money Penalties: What to Know & How to Prepare.
If your organization believes it is “stuck” with an unfavorable CMS WCMSA determination amount or has any questions regarding the upcoming Amended Review policy change, please contact us.
[1] Re-Review, the second recognized administrative remedy, remains available immediately pursuant to certain conditions. If you have questions regarding whether your workers’ compensation claim is eligible for Re-Review or Amended Review, please contact us.
