When is the right time to get a Medicare Set-Aside? What medical information is needed? And what can you do to expedite the CMS approval process?
These questions plague any organization trying to settle workers’ compensation claims with injured workers who are or soon will be eligible for Medicare. But understanding when, how and why MSAs are most appropriate allows payers to work proactively with an MSA vendor to reach settlements that are in the best interests of all parties involved.
Anne Alabach, the Workers’ Compensation Department Manager of CPC Logistics, joins Daniel Anders, Chief Compliance Officer at Tower MSA Partners to discuss Achieving Great Outcomes with Your MSA Vendor during the National Workers’ Compensation and Disability Conference® & Expo next month at Mandalay Bay Resort in Las Vegas.
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“8 ‘Think Outside the Box’ Tactics to Settle Workers’ Comp Claims”
The session will focus on the key indicators to determine success or need for improvement, ways to leverage partner relationships to drive down unneeded MSA costs, and variables that can significantly affect the amounts of MSAs as well as approval times from the Centers for Medicare and Medicare Services (CMS).
Prime Variables
There are a variety of factors that go into developing an MSA. There is not necessarily a ‘right’ or ‘wrong’ amount. What’s important is that the injured worker has enough money to pay for his injury-related medical expenses throughout his life, and the payer is not incurring irrelevant and/or unnecessary costs.
In addition to meeting the threshold for needing an MSA, injured workers should be at maximum medical improvement before one is even considered. An employee who’s about to undergo surgery or a change in medications is not at the point where an MSA should be developed.
Instead, it is most appropriate when the worker’s condition has stabilized.
The variables that should be considered to achieve the most suitable MSA include:
- Time
- Documentation
- Legal
- Medical
- CMS MSA Review
Timing of the MSA
Time is of the essence — unless it’s not the right time for an MSA. As described above, prior to MMI is the wrong time to establish an MSA. Changes in treatment or services will undoubtedly mean new medications or procedures will be needed, at least in the short term. The MSA should, instead, be developed when there is a reasonably strong chance the person’s medical requirements won’t vary much going forward. CMS’ MSA review program is actually designed for the injured worker who is already at MMI.
However, MMI does not necessarily indicate all medications and other medical needs are appropriate; far from it. For example, medical records for the injured worker may include a medication that was prescribed just one time, months or years ago. It is not uncommon to see medications included in the MSA that the injured worker doesn’t even remember taking.
Uncovering those types of issues is invaluable in reducing unnecessary costs from the MSA. Talking with the MSA vendor about the injured worker’s current situation may reveal clinical interventions that place the case in a more favorable position.
Also, there may be case-specific recommendations based on jurisdictional issues and opportunities that would change the MSA amount. Working with a qualified MSA vendor can lead to major changes in MSA costs.
The Right Documents
Workers’ compensation stakeholders are often frustrated by delays in the CMS approval process. While some of the blame may fall on the agency, it is often the result of insufficient or inconsistent information provided. “An MSA is only as good as the information it is based upon,” according to Anders. Failing to give accurate and complete information may result in letters from CMS and errors in the MSA amount.
“Put yourself in CMS’ shoes,” Anders advised. That means to obtain and provide recent treatment records, or an explanation as to why those documents do not exist. Also, contradictory recommendations need to be corrected. The MSA vendor can ensure the right documentation is provided and is properly filled out.
Legal & Medical Issues
There may be legal justification to exclude or limit medical care in the MSA. Working closely with the MSA vendor can identify those issues.
Physician peer review, clinical oversight, and physician follow-up are the types of interventions that are critical in creating MSAs. Every aspect of the injured worker’s future medical needs must be explored, by obtaining and analyzing his past medical care. Inappropriate care that may be huge cost drivers should be singled out and eliminated where possible, while still ensuring the injured worker’s care is optimized.
Date of injury, accepted and denied dates of injury and body parts, compensable injuries, & diagnosis codes are just a few of the many things that must be considered.
CMS Review
Gaining CMS approval for the MSA, while not required by law, is often a best practice. The outcomes of these reviews are largely predictable — once the process is well understood.
Correctly following the guidelines in the CMS WCMSA Reference Guide, using the correct pricing in fee schedules and recognizing statutory limitations are a few of the factors that can lead to CMS approval.
Certain metrics identified in the MSA preparation and submission process can allow reverse engineering to correctly allocate the MSA and identify obstacles to settlement. An experienced MSA vendor can help pinpoint and analyze metrics to get CMS approval as quickly as possible.
Conclusion
Creating an MSA can be tedious, painstaking work, especially for those whose jobs are not solely focused on them. Those MSAs that gain quicker approval from CMS and are properly funded are developed by payers working in conjunction with MSA vendor partners who have the skills to carefully look at a myriad of factors that impact the injured worker and his medical needs.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 the founder & lead trainer of Amaxx Workers’ Comp Training Center.
Contact: mstack@reduceyourworkerscomp.com.
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