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

Before Header

  • About
  • Contact
  • Privacy
 
Ametros

Amaxx Workers Comp Blog

Reduce Workers Compensation Costs By 20-50%

Header Right

  • Home
    • Training Center
  • Search
    • Free Resources & Solutions
    • Subscribe to Free Newsletter
    • Create Free Training Center Account
    • Enroll in On-Demand Courses
    • Activate WC Mastery Membership
    • Request Strategic Coaching Session
    • Buy WC Guidebooks
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
    • Coaching
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login

Mobile Menu

  • Home
    • Training Center
  • Search
    • Free Resources & Solutions
    • Subscribe to Free Newsletter
    • Create Free Training Center Account
    • Enroll in On-Demand Courses
    • Activate WC Mastery Membership
    • Request Strategic Coaching Session
    • Buy WC Guidebooks
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
    • Coaching
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login
  • About
  • Contact
  • Privacy
You are here: Home / Claims Resolution and Settlement / Medicare Set Asides (MSAs) / How to Control the 5 Variables that Impact MSA Amounts and Approvals

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

October 23, 2019 By //  by Michael B. Stack

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

Click Link to Access Free PDF Download

“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:

  1. Time
  2. Documentation
  3. Legal
  4. Medical
  5. 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.

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

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.

Michael Stack - Amaxx 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.

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

©2019 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

Tips and Traps to Effective Medicare Secondary Payer Compliance

Tips and Traps to Effective Medicare Secondary Payer Compliance

Tips and Traps to Effective Medicare Secondary Payer Compliance

Tips and Traps to Effective Medicare Secondary Payer Compliance

Experts Explain How to Prevent Losing Continuation of Care Post-Settlement

Experts Explain How to Prevent Losing Continuation of Care Post-Settlement

Medicare Secondary Payer Compliance Claim Handling Tips

Medicare Secondary Payer Compliance Claim Handling Tips

Tips for Navigating the Evolving Medicare Set-Aside Landscape

Tips for Navigating the Evolving Medicare Set-Aside Landscape

Ensure an Individual’s Medicare Set Aside is Maintained Post-Settlement

Ensure an Individual’s Medicare Set Aside is Maintained Post-Settlement

You Have Your MSA Allocation Report – Now What?

You Have Your MSA Allocation Report – Now What?

The Devastating Risks of Failing to Comply with Medicare Requirements Post-Settlement

The Devastating Risks of Failing to Comply with Medicare Requirements Post-Settlement

Medicare Secondary Payer Update: Time to Update your Compliance Program

Medicare Secondary Payer Update: Time to Update your Compliance Program
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

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: «professional administrator 5 Criteria to Choose the Right Professional Administrator
Next Post: Medcor Announces the Purchase of Proactive Occupational Medicine »

Primary Sidebar

FREE DOWNLOAD

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

Our Sponsors

Post-Settlement Administration
 

ARCADIA - Enhancing Settlement Outcomes

The Structured Settlements Company
 

Catastrophic and Risk Solutions, Case Management Solutions, and Specialty Networks
 

Medcor

Injury Triage, Onsite Clinics

Read Our Award-Winning Blog

Blog Categories

Search Our Archive

Subscribe to Our FREE Newsletter

Return-to-Work Essentials

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
  • Return-to-Work Essentials

RSS Recent Blog Posts

  • Dealing with Death: A Claim Handler’s Primer to Death Claims
  • Tips and Traps to Effective Medicare Secondary Payer Compliance
  • Work Comp Expectations Dictate Injured Worker Experience
SUBSCRIBE TO OUR FEE NEWSLETTER
Let Us Help You Stomp Down the High Cost of Workers' Comp!
Top of Page ↑
  • Home
  • Training Center
  • Search
  • Membership
  • Products
  • Blog
  • About
  • Contact
  • Subscribe
  • Login
Copyright © 2022 Amaxx, LLC. All Rights Reserved. · Privacy Policy / Legal Notice