Selecting the right Medicare Secondary Payer (MSP) compliance service provider is an important part of any claims operation. These service providers are essential when it comes to making sure a claim complies with all aspects of the Medicare Secondary Payer Act by providing suggestions to help resolve troublesome cases. This must include a focus on selecting someone who provides innovative solutions to complex problems.
Understanding the Medicare Secondary Payer Act
The Medicare Secondary Payer Act was passed into law in 1980, but was largely ignored until the late 1990s. Since that time, claim management teams have paid considerable attention to compliance with the Act by considering Medicare’s interests in all workers’ compensation claims.
One part of MSP compliance is the projection of future medicals related to injury-related claims. This includes the careful review of medical records related to the injury and projecting costs associated with future medical care reimbursable by Medicare. The result should be a medical cost projection that is reasonable. Another factor is an acceptable approval rate for those allocations submitted for review and approval under the voluntary workers’ compensation Medicare Set-aside submission process.
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Threshold Factors for Consideration
There are several threshold factors for consideration when selecting a MSP compliance service provider. When making this decision, it is important to answer the following:
- How would you describe your current MSP compliance program for workers’ compensation?
- What is the MSP compliance provider’s experience and expertise including legal/compliance, and pharmaceutical/medical?
- How are clinical interventions handled? Is the process seamless?
- What is your criteria for success? (or how do you measure success?)
- What is the level of communication your current MSP partner provides during the Medicare-related processes?
By answering these questions, the leadership within a claims management team will understand the importance of a provider that offers innovative services.
Moving Beyond the Basics of MSP Compliance
Countless MSP service providers do an excellent job providing precise medical allocations. While this is an important component of effective compliance efforts, it is important to seek a provider who is able to offer innovative services that take the extra steep.
- A sophisticated service provider utilizes technology that drives all compliance related processes. This includes the ability to manage in an effective manner the three main components related to the MSP Act: conditional payment resolution; Medicare Set-asides; and Section 111 Mandatory Insurer Reporting.
- Pre-MSA Triage. Stopping problems before they occur is an important component missing in most MSP compliance programs. When selecting the right service provider, it is essential to work with a provider that can identify barriers to settlement and provide specific intervention recommendations. This should include physician peer review, drug utilization review and clinical oversight.
- Compliance automation and tracking services. Automation allows interested members of the claim management team to track Medicare related activity on a claim from the time a beneficiary is identified through final settlement via end-to-end visibility. It also allows team members to view in real-time what actions the MSP service provider is taking and what additional steps will occur in the future. This includes communication with physicians, pharmacists, conditional payment searches, and medical/pharmaceutical interventions. This not only give claim handlers peace of mind, but also frees them to address issues that require attention.
Conclusions
Effective MSP compliance includes a service provider that goes beyond the basics. These providers will offer services that allow members of the claim management team to focus on their job and provide information and resources to comply with Medicare regulations in workers’ compensation claims.
Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: [email protected].
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