Workers Compensation Medicare Set-aside Agreements Explained
Benefits for Workers Compensation Medicare expenses must be protected for the CMS. It is the responsibility of all parties to protect Medicare’s interests when resolving cases with future medical expenses. Forecasting future Workers Compensation medical benefits can be very complicated.
The recommended method for doing this is a MSA, which allocates a portion of the settlement for future medical expenses. The amount of the set aside is determined on a case-by-case basis and is mandated to be reviewed by the Centers for Medicare and Medicaid Service (CMS) when appropriate. Once the CMS determined amount is exhausted and properly accounted for to CMS, then Medicare/Medicaid will agree to be the primary payer for future Medicare covered expenses related to the injury.
Evidence has shown that there are five key factors organizations should be focused on in 2009 and 2010 to settle and manage these cases.
• Continuous review of their cases to establish MSA thresholds for minimizing risks and maximizing compliance.
• Reserves should be carefully reviewed and benchmarked on a case-by-case basis to be certain they are optimal and segmented to each area of future expense.
• Retention of an experienced team of multi-disciplinary medical, financial, claim, and legal resources with significant experience in settling high value cases.
• A “Zero Approval” goal for each case by removing co-morbidity factors, and only relating the subject injury to the proximate cause.
• Service quality and technology dedicated to carefully managing and ensuring excellence throughout the process.
While many organizations have qualified representatives who are capable of managing the smaller cases, only a few have the dedicated resources to focus on the complex laws and regulations surrounding MSA’s.
The CMS is continually changing their rules and opinions, and it requires a consistent team of practice professionals to provide organization and clarity for each case. With this team, the organization can be assured of a careful and thoughtful approach which will receive final approvals and future certainty for the cases.
The CMS had produced a memo earlier this year that changed the rules on MSA’s. If your company has not heard of MSA’s from your carrier or Third Party Administrator (TPA) and you have had serious claims in the last 10 years, you may want to start inquiring NOW.
PLEASE NOTE THAT IF YOU SELF INSURE OR HAVE A HIGH DEDUCTIBLE PROGRAM – YOU AS THE EMPLOYER AND NOT THE TPA BEARS THE RESPONSIBILITY OF REPORTING THIS INFO PROPERLY TO THE CMS. With so many government funding shortfalls, this is an area where the Federal Government is going to increase their enforcement.
Next Up – The New CMS Memo
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