There could be several correct answers to the question above. For CMS review purposes, the correct answer is typically 6 months because CMS requires a claim payment history generated within 6 months of the submission date. If an updated payment history includes payment for dates of treatment subsequent the prior MSA analysis then the medical records for the subsequent treatment will be a required part of the CMS submission. And there may be new treatment or medication recommendations in the subsequent records that could have significant impact on the MSA recommendation.

On the flip side, if the MSA analysis included cost projections for a surgery that has been done then you would want to have it updated prior to CMS submission regardless of the time elapsed. A change in the medication regimen may also represent an opportunity for a significant MSA reduction with an updated MSA analysis.

Keep in mind also that the Redbook AWP pricing methodology employed by CMS for pricing of prescription medications is subject to monthly changes. Although monthly changes are not frequent, they do occur and more often when a brand name prescription medication is included in the pharmacy portion of the MSA cost projections. When forecast over the beneficiary’s life expectancy, even a $0.50-1.00 increase in cost per pill will have a significant impact on the total MSA amount.

OWCP fee schedule and many state WC fee schedules are updated annually. These updates almost always result in increased reimbursement rates for medical providers which could result in variance between the pricing used by the MSA allocator versus pricing used in the CMS review process. These fee schedule increases are typically less than 5% but again extrapolated over a 20 year plus life expectancy it could result in a noticeable increase in the total MSA amount.

Getting back to the original question, the only always correct answer is it depends on the fact scenario on each individual claim. At MAPS Medical we are happy to review the facts and assist you in answering that question timely and correctly.