• Menu
  • Skip to main content
  • Skip to secondary navigation
  • Skip to primary sidebar
  • Skip to footer

Before Header

  • Search
  • About
  • Contact
  • Privacy
 
CHOOSE BROADSPIRE

Amaxx Workers Comp Blog

Reduce Workers Compensation Costs By 20-50%

Header Right

  • Home
    • Training Center
  • Get Started
    • Newcomers Class for WC Professionals
    • Subscribe to Free Newsletter
    • Free Training Center Account
    • Return to Work Resources
    • WC Claims Mgmt. Resources
    • Insurance Advisor Resources
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login

Mobile Menu

Choose Broadspire

CHOOSE BROADSPIREBroadspire Delivers Meaningful Results to Our Clients and Their Claimants
  • Home
    • Training Center
  • Get Started
    • Newcomers Class for WC Professionals
    • Subscribe to Free Newsletter
    • Free Training Center Account
    • Return to Work Resources
    • WC Claims Mgmt. Resources
    • Insurance Advisor Resources
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login
  • Search
  • About
  • Contact
  • Privacy
You are here: Home / Claims Resolution and Settlement / Medicare Set Asides (MSAs) / Identify and Realize Medicare Set-Aside Savings Opportunities

Identify and Realize Medicare Set-Aside Savings Opportunities

May 2, 2017 By //  by Michael B. Stack Leave a Comment

The rising costs of workers’ compensation come in many different forms.  One such way members of the claims management team are seeing these increases is in Medicare Set-aside allocations and future medicals.  This issue presents a challenge for all teams and to meet this challenge a MSA service provider should be utilized that employs creative tools to reduce an allocation in a reasonable and ethical manner.  One such mechanism is the use of physician intervention by following up with the employee’s treating physician to confirm the accuracy of all treatments and prescriptions drugs in the allocation.

Back to the Basics of MSA Allocation Preparation

There is a certain art to preparing and writing a MSA allocation.  This includes the threshold matter of ensuring the allocation is reasonable, and will be accepted if it is sent for voluntary review and approval by CMS.

When writing an accurate MSA allocation, the person preparing the report will rely on some or all of the following materials and records:

  • All medical records for the last two years of treatment related to the WC claim*;
  • A complete claim payment history record from the insurance carrier;
  • A separate pharmacy payment history report;
  • Draft settlement documents, prior settlements, court orders and decisions and other legal documents;
  • A First Report of Injury; and
  • Explanation of accepted, disputed and denied body parts, along with ICD-10 codes.

* “Treatment records” consist of all medical records for treatment to the claimed body part or condition even if the employer or carrier did not pay for the treatment.  Also, CMS does not consider an Independent Medical Examination report a “medical record” for purposes of allocation review and approval.

Click Link to Access Free PDF Download

“8 ‘Think Outside the Box’ Tactics to Settle Workers’ Comp Claims”

Cost Drivers in MSA Allocations

Medical costs in workers’ compensation claims continue to rise with a large portion of future medical tied to pharmacy costs. A September 2016 NCCI research brief states “for every $100 of medical services paid on claims older than 10 years, approximately $45 to $50 will be for prescription drugs.” This leads to an increased future medical component that must be considered as a part of every settlement.  Members of the claims management team should monitor their files for the following issues:

  • Pharmacy savings opportunities: Medications that are prescribed, but never actually filled by the employee, prescribed medications that have been discontinued, and brand name drugs that can be replaced with generics.
  • Medical savings opportunities: Ongoing and prolonged treatment by a primary care doctor for injuries that should require a specialist, gaps in a patient’s medical record and treatment recommendations which are no longer considered viable, such as a spinal cord stimulator. 

Physician Intervention – Brand vs. Generic Drugs

There are many opportunities for members of the claim management team to reduce the cost of a MSA allocation and promote a culture of settlement.  One such strategy is directly contacting the employee’s treating physician to follow up on medical cost driver red flags and savings opportunities.  As a note of caution, this should be done in conformance with federal and state law and may require the approval of the injured worker.

A classic example of when direct physician intervention is appropriate comes after a review of prescription records.  Often the physician prescribes a certain brand name medication versus a therapeutically equivalent generic.  While not always the case, generics are often considerably less expensive and offer the same medicinal attributes as the brand name.

An experienced MSA service provider will notice this opportunity by reviewing the “dispense as written” (DAW) codes in medical and pharmacy records.  They will position your file for the cost-saving measure to recommend direct contact with the physician to revise the prescription for the cheaper alternative.  Communication between the parties allows the necessary change to occur.  The cost savings will be realized once that cheaper alternative is filled by the pharmacy and a paper trail is created.  This allows the allocator to document the file and justify the lower prescription drug costs. 

FREE DOWNLOAD: “8 ‘Think Outside the Box’ Tactics to Settle Workers’ Comp Claims”

Physician Intervention – Discontinued Medications

Another opportunity for MSA cost reduction is to identify and confirm the discontinuation of medications previously prescribed.

Medicare Set-asides: A Case Study

 

*case study provided by Tower MSA Partners

The main cost driver in this MSA allocation was the cost of prescription drugs.  In the above example, a review of the pharmacy recorded revealed Amitiza, Pantaprazole, and Meloxicam were prescribed, but had not been filled for an extended period of time. This represented a significant opportunity for savings by directly following up with the treating physician in writing to confirm these prescriptions had been discontinued. This confirmation allowed the prescriptions to be removed from the allocation, resulting in $200,113 in savings.

Conclusions

The ever-increasing price of medicals on workers’ compensation presents a series of challenges for the claims management team.  In order to avoid over-allocating for treatment and prescription medications, leverage a proactive MSA service provider to identify MSA savings opportunities and intervene with the treating physician.  This proactive approach often results in a lower MSA allocation with realized cost savings to the claims management team.

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

FREE DOWNLOAD: “8 ‘Think Outside the Box’ Tactics to Settle Workers’ Comp Claims”

Filed Under: Medicare Set Asides (MSAs)

Related Articles

Understanding of MSA Compliexity

Medicare Secondary Payer: Issues that Will Impact Work Comp in 2021

Medicare Secondary Payer: Issues that Will Impact Work Comp in 2021

Get a Second Opinion on Your Medicare Set-Aside (MSA)

Get a Second Opinion on Your Medicare Set-Aside (MSA)
Settlement

Settle More Workers’ Compensation Claims During the COVID-19 Pandemic

Settle More Workers’ Compensation Claims During the COVID-19 Pandemic

8 Ways to Stay Out of Medicare’s Penalty Box

8 Ways to Stay Out of Medicare’s Penalty Box
Reduce your workers' comp case study

Case Study: $101,312 Savings Through MSA Amended Review Process

Case Study: $101,312 Savings Through MSA Amended Review Process

A Prescription for Settling Legacy Claims

A Prescription for Settling Legacy Claims

Increased Penalties are Coming for Incorrect Medicare Secondary Payer Reporting

Increased Penalties are Coming for Incorrect Medicare Secondary Payer Reporting

4-Step Strategy to Successfully Settle Workers’ Comp Claims

4-Step Strategy to Successfully Settle Workers’ Comp Claims

CMS Expands MSA Amended Reviews & Modifies Consents To Release In Updated Reference Guide

CMS Expands MSA Amended Reviews & Modifies Consents To Release In Updated Reference Guide

How to Control the 5 Variables that Impact MSA Amounts and Approvals

How to Control the 5 Variables that Impact MSA Amounts and Approvals

Terminate ‘Ongoing Responsibility for Medicare’ (ORM) or Invite Big Problems

Terminate ‘Ongoing Responsibility for Medicare’ (ORM) or Invite Big Problems

Eliminate ‘MSA Fear’ In Upcoming WCI Session in Orlando

Eliminate ‘MSA Fear’ In Upcoming WCI Session in Orlando

Free Download

8 'Think Outside The Box' Tactics To Settle Workers' Comp Claims - FREE Download Click Here Now!

Train to Succeed

BECOME CERTIFIED IN WORKERS’ COMPENSATION

Proven Course Catalog & WC Toolbox Give You The Power To Achieve Lower Costs and Better Injured Worker Outcomes

VISIT WORKERS' COMP TRAINING CENTER

Previous Post: « RIMS 2017: Leverage Michael J. Fox’s Lessons to Prevent Creeping Catastrophic Claims
Next Post: 7 Ways to Proactively Reduce Comorbidity Costs »

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Primary Sidebar

FREE DOWNLOAD

8 'Think Outside The Box' Tactics To Settle Workers' Comp Claims - FREE Download Click Here Now!

Our Sponsors

Ametros

Post-Settlement Administration
 

Broadspire

Workers’ Comp 3rd-Party Administrator
 

Medcor

Injury Triage, Onsite Clinics
 

Catastrophic Care Management, Complex Care, and Specialty Networks
 

Read Our Award-Winning Blog

Blog Categories

Search Our Archive

Subscribe to Our FREE Newsletter

Footer

Search Our Archive

Search our continually growing archive of over 2500 articles about Workers' Comp issues.

Quiclinks

  • Calculators
  • Terms & Abbreviations
  • Glossary of WC Premium Terms
  • WC Resources
  • Best Practices
  • Industries

RSS Recent Blog Posts

  • Timely Reporting Claims Is First Step In Work Comp Management
  • Using Defense Attorneys to Defend Work Comp Cases
  • Settle More Workers’ Comp Claims Faster With The Team Approach
SUBSCRIBE TO OUR FEE NEWSLETTER
Let Us Help You Stomp Down the High Cost of Workers' Comp!
Top of Page ↑
  • Home
  • Training Center
  • Get Started
  • Membership
  • Products
  • Blog
  • About
  • Contact
  • Subscribe
  • Login
Copyright © 2021 Amaxx, LLC. All Rights Reserved. · Privacy Policy / Legal Notice