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

Before Header

  • Search
  • About
  • Contact
  • Privacy
 

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

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

November 30, 2020 By //  by Michael B. Stack

Ever get close to settling a claim only to find the Medicare Set-Aside is a problem? Either the amount seems too low for the injured worker, or it seems too high for the payer. What do you do? How can you know if an MSA is appropriate for both sides and does not shift the burden of future medical to Medicare?

As much as you might seek a second opinion for a medical issue, getting an outside party to take a look at the MSA isn’t a bad idea — especially since the good ones will do it for free.

Potential problems

On its face, an MSA seems like it should be fairly straightforward. It’s an allotment of money to cover the injured worker’s medical needs for life. The idea is to make sure that the MSA portion of the settlement is available to cover future medical expenses, so they do not become the responsibility of Medicare to pay.

You might think it’s a simple matter of looking at the injured worker’s current medical expenses and extending them for the person’s expected lifespan, figuring in estimated inflationary costs. What seems like it should be a relatively simple process is anything but simple.

There are any number of things to include — or not — in an MSA. For example:

  • Only costs related to the actual work injury should be included
  • Only medications/procedures covered by Medicare should be included
  • Only body parts associated with the claim and for which the payer has been paying should be included
    Click Link to Access Free PDF Download

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

While those are among the basic issues to consider for MSAs, getting a truly accurate picture takes a thorough analysis and working with treating physicians to clarify ongoing treatment and medications.

For example, a careful review of medications might reveal that some are not specific to the accepted body parts. Or it may uncover the use of expensive, brand name drugs where generics could be substituted.

Looking at the provider’s notes might indicate recommendations for specific treatments that have may no longer be under consideration or even be totally inappropriate for the injured worker’s condition.

Among other potentially unnecessary cost drivers in MSAs are:

  • Never filled or discontinued drugs
  • Lag time in pharmacy price reductions, , e.g., lower price of a medication such as Meloxicam not reflected in MSA
  • Use of inaccurate CPT codes and number of physician visits/year
  • Urine drug screen test frequency and coding issues

Changes to the MSA

Finding unnecessary expenses is only part of the solution. It’s imperative to make sure that making changes or eliminating anything from the proposed MSA is done in a way that meets the approval of treating physicians — especially if seeking the approval from the Centers for Medicare and Medicaid Services.

While CMS approval for MSAs is not required by law, in many cases it is the prudent action to take to protect all parties. Those with expertise in the CMS approval process can save time and money.

An example is the inclusion of MSA funds for medications and/or treatments that are not valid; either they are not appropriate for the person or, more than likely, they are no longer recommended. To confirm/verify, MSA experts need to speak with the treating physician who made the recommendations.

Frequently, the issue has been overlooked and never deleted from the physician’s notes. Having an MSA professional speak with the provider often results in getting agreement and written confirmation that the medication/procedure is no longer needed. That alone can save thousands of dollars in an MSA.

In some cases, a letter from the MSA vendor to CMS is warranted. For example, a ‘Body Part Letter’ can clarify what conditions are or are not being paid for by the insurer. That can also result in thousands of dollars saved by removing medications or treatment associated with the wrong body part.

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

The expected lifespan of the injured worker is also key to developing an accurate MSA. The person’s injury and comorbid conditions may dramatically change his life expectancy. A 35-year old male, non-smoker in tip top shape has a longer life expectancy than a 35-year old smoking male with hypertension, diabetes, and a severe injury. Using a ‘rated age’ can reduce the amount of the MSA to account for the discrepancy.

Working with CMS

Getting CMS approval for an MSA can be hugely challenging for those not intimately familiar with the agency’s processes. However, MSA experts who work with CMS day in and day out understand what needs to be done. These professionals understand when to press on against CMS arguments and when it is a losing endeavor. It’s also imperative to stay abreast of the continuing updates from CMS, such as coverage, coding and individual state pricing data. Those who have paid careful attention to CMS responses for years have unique insights into what CMS will and won’t accept. MSA experts understand how to nuance the phraseology and provide the specific documentation geared to a more likely acceptance from CMS. Finally, MSA experts are able to fully explain and defend the MSAs they provide.

Conclusion

Injured workers are much more likely to settle their claims if they believe they have the appropriate support and funding they need for the future. While ensuring that is crucial, it’s also vital to provide a settlement — and MSA — that meets their needs without costing unnecessary dollars for payers.

Michael Stack - AmaxxAuthor 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, which offers the Certified Master of Workers’ Compensation national designation.

Contact: mstack@reduceyourworkerscomp.com.

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

©2020 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

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

Bringing Understanding of MSA Complexities at WCI in Orlando

Bringing Understanding of MSA Complexities at WCI in Orlando
Generic drugs in workers' compensation

Case Study: More than $1.5 Million in Savings Through Generic Substitutes

Case Study: More than $1.5 Million in Savings Through Generic Substitutes

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: « Avoid Workers’ Comp Litigation
Next Post: Settle Workers’ Comp Cases To End the Year »

Primary Sidebar

FREE DOWNLOAD

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

Our Sponsors

Medicare Secondary Payer Services
 

Ametros

Post-Settlement Administration
 

Broadspire

Workers’ Comp 3rd-Party Administrator
 

Hiring and Return to Work Testing
 

Catastrophic Care Management, Complex Care, and Specialty Networks
 

Medcor

Injury Triage, Onsite Clinics

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

  • Big Employer Mistake In Work Comp is No Employee Rapport
  • 20 Unfair Claim Practices For Your Adjuster To Avoid
  • Use Vocational Coordination When Employees Are Unable To Return to Work
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