Medical Review Services
Pre-Settlement Services
Certified Life Care Plans
A Certified Life Care Plan is a comprehensive report that forecasts the future medical needs and related costs throughout the life expectancy of a catastrophically injured person, or one with a devastating, life long illness. Life Care Plans evaluate all aspects of medical and are based on long-term goals.
When a severe injury occurs or a serious illness onsets, it can be devastating for both the individual and their loved ones. Every injury and illness is different for each person, this is why our Life Care Plans are tailored to the individual. Our Certified Nurse Life Care Planner reviews medical records, conducts an on-site visit and engages in direct contact with the individual to gain an accurate account of future long term care and medical needs. It is imperative that every aspect of the injury or illness is medically evaluated in order to determine the future medical costs.
What are the benefits of a Certified Life Care Plan?
A Certified Life Care Plan is beneficial because it provides a detailed analysis of the individual’s future medical needs. Certified Life Care Plans serve as a great tool for quantifying current and long term medical needs, which provide our clients with accurate calculations of long term care.
Life Care Plans are comprehensive, medical evaluations that can assist with future medical costs for settlement purposes, to ensure that your client has sufficient funds over the course of their life expectancy.
A Certified Life Care Plan is an excellent way of ensuring the highest quality of life the injured or ill person.
Certified Life Care Plans are calculated based on fee schedule or usual and customary.
Our Certified Life Care Plans:
- Includes a detailed summary of the case and nature of injury/illness,
- Highlights ICD-9 codes relevant to injury,
- Provides a detailed chronological medical review,
- Reports future medical requirements,
- Includes a medical cost analysis summary and calculations
- and more!
Specialty Allocations specializes in life care planning for individuals with:
- Orthopedic Injury
- Traumatic Brain Injury
- Spinal Cord Injury
- Birth Trauma/Defects
- Neurological Disorders
- Other catastrophic injury or illness
Medicare Set Asides
What is a Medicare Set Aside (MSA)?
A Medicare Set Aside (MSA) report determines the amount of settlement dollars to be “set aside” or allocated for future injury-related medical expenses typically covered by Medicare in a Workers’ Compensation or liability case. An MSA is recommended by the Medicare Secondary Payer (MSP) statute in the settlement of workers’ compensation claims to avoid shifting the burden from the primary payer to Medicare. Everyone involved within a workers’ compensation case are responsible for protecting Medicare’s interests, under the Medicare Secondary Payer (MSP) laws. MSAs are the MSP’s recommended strategy for protecting the future of Medicare. “If Medicare’s interests are not considered, Center for Medicare and Medicaid Services (CMS) has priority right to recovery against any entity that received a portion of a third party payment either directly or indirectly” (WCMSA Reference Guide, March 29, 2013).
The funds allocated in the Medicare Set Aside are to be used to pay for medical services and prescription drug expenses related to the injury that would be covered by Medicare. Under certain circumstances, this proposal is required to be sent to the CMS for approval.
Why do I need a Medicare Set Aside (MSA)?
A Medicare Set Aside (MSA) is not required for any settlement; however, the Center for Medicare and Medicaid Services (CMS) recommends that you take Medicare’s interest into consideration for all settlements that involve a current Medicare recipient and/or injured person that will be eligible for Medicare within 30 months of settlement. If your client needs legal advice on a case, we can refer a client to a MSP legal expert to discuss the nature of their case. The CMS website also serves as a great reference, the client can review information and memorandums pertaining to the thresholds. We are not legal experts and cannot offer legal advice. In a nutshell, executing a MSA proposal basically means one is acting in “Good Faith” to protect their client’s future Medicare benefits and properly omitting any future conditional payments made by Medicare relating to the injury incurred.
Specialty Allocations’ Process for Medicare Set Asides
Our nurses and Medicare Set Aside specialists base the MSA process on the “accuracy” of the future medicals. We strive to complete the MSA report within 7 to 10 business days (a rush case can be completed within 5 business days for an additional fee). Once we receive 3-5 years of medical records, entire claim payout history, and 2 years of prescription drug history, we begin an in-depth, chronological review. We obtain a rated age for each case. We send out Medical Assessments to treating physicians to obtain a true estimate regarding any anticipated surgery, procedures, and proper dosage on any prescribed medications. Our MSA Specialists examines all of this information to make recommendations based on the amount of future medical care the injured will require that is covered by Medicare. We report the injuries to the Coordination of Benefits Contractor (COBC), if they have not been previously reported.
If the MSA Specialist has any questions or concerns during the medical review process, they will contact the referral source immediately. Direct communication is important to us. Upon completion of the report, the MSA Specialist submits the MSA for review by another nurse for quality assurance purposes to verify accuracy. We will send the completed MSA report directly to the referral source via e-mail in a PDF format. Hard copies are available upon request.
Workers’ Compensation Medicare Set Aside (WCMSA) vs. Liability Medicare Set Aside (LMSA)
Workers’ Compensation Medicare Set Asides (WCMSA) are based upon the “State of Jurisdiction” the injury occurred and that particular state’s specific Workers’ Compensation fee schedule. (Please Note: The following states do not have a fee schedule: Indiana, Iowa, Missouri, New Hampshire, New Jersey. A fee schedule is not to be used in a state that does not have a fee schedule. ) WCMSA for settlements $25,000 or more are obligated to submit to CMS for approval.
Liability Medicare Set Asides (LMSA) are based upon the state where the injured person resides and usual and customary charges. LMSAs are not required to be submitted for CMS approval.
Our customer service is a cut above any other MSA vendor. Our clients are able to have open communication with the nurse and/or MSA Specialist who prepared your report. We are here to answer your questions and concerns, we value being available as a reliable resource.
CMS Submissions
Specialty Allocations sends Medicare Set Aside proposals to CMS upon the request of the referral source. A cover letter is generated notifying of the submission. We provide ongoing status updates of the submission until a decision is reached by CMS.
Submitting a Medicare Set Aside to CMS for Approval
CMS’s Review Thresholds for WCMSAs:
Medicare Set Asides are recommended for submission to CMS when they meet the following criteria:
- The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or
- The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00.
A claimant has a reasonable expectation of Medicare enrollment within 30 months if any of the following apply:
- The claimant has applied for Social Security Disability Benefits
- The claimant has been denied Social Security Disability Benefits but anticipates appealing that decision
- The claimant is in the process of appealing and/or re-filing for Social Security Disability benefits
- The claimant is 62 years and 6 months old
- The claimant has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.
For MSAs that meet the mentioned criteria, we will send a Medicare Set Aside proposal to CMS upon the request of the referral source. A cover letter is always given to the referral source for their record keeping. We follow up with our proposals every two weeks until an approval is obtained.
Medical Cost Projections
Specialty Allocations’ Medical Cost Projections (MCP) compiles information from both past and present medical records to accurately project future medical costs throughout the claimant’s lifespan. Medical Cost Projections serve as an invaluable resource for forecasting future medical exposure and future medical costs for settlement purposes.
Our MCP reports are prepared by Registered Nurses. They provide a comprehensive medical analysis of all related medical and prescription drug costs associated with an injury or illness. Medicals are reviewed from all treating sources, in addition to claim payment history and prescription drug history. The Medical Cost Projection provides a detailed, chronological summary and identifies what is related and what is unrelated to the injury. The Medical Cost Projection can aid as a tool in setting reserves in workers’ compensation and liability claims.
Our Medical Cost Projection reports provides nurse recommendations on future medical care. The report takes into consideration the lifetime projected costs such as physician visits, diagnostics, future procedures, and medications.
Medical Cost Projections do not require an onsite visit. “Present day value” serves as the baseline for future medical needs. MCP report can be based on the claimant’s actual age or rated age. The MCP report is completed within 10-14 business days, rush case is available for an additional charge.
Home Assessments
A Home Assessment is a comprehensive functional status and current needs assessment based upon the injury related diagnosis and the nursing process. The home assessment includes, but is not limited to, assessment for safety issues, attendant care services, home renovations, sharing of resource information and community based services. Our nurses review medical records and conduct an onsite visit to identify the service needs of the injured individual and determine recommendations to help the individual thrive within their home environment.
In most cases, Home Assessments include an Attendant Care Assessment. Attendant Care Assessments determine the client’s current level of pre and post injury functionality to perform personal tasks such as dressing, bathing, grooming, hair care, etc. The Home Assessment report is based on the conducted assessment, which also includes recommendations to minimize functional barriers, promote client’s recovery, and allow the client to gradually return to their personal care activities. Our goal is to determine what will help restore the client to as much independent function as possible.
Home Assessments are completed by registered nurses, familiar with home care modifications. The onsite evaluation of the client’s place of residence, helps the nurse accurately assess their needs.
Our Home Assessments are detailed and include:
- Nature of injury synopsis
- Detailed chronological medical review
- Evaluation of post injury needs
- Identifies the care needs of the injured individual
- Comprehensive functional status and current needs assessments
- Recommended plan by nursing professional
- and more!
Nurse Reviews
Our medical review reports are completed by registered nurses who chronologically detail the medical treatment of the injured person. Our nurses are equipped with years of expert medical legal experience and our reports support the facts of the case.
Medical records are thoroughly reviewed from the onset of the injury/illness to present day. The medical review report creates a clear, comprehensible timeline for the referral source.
Our medical review report, completed by using the critical thinking skills of a registered nurse, provides you assistance on cases that involve specific concerns of treatment, address concerns regarding over or under utilization of treatment services, or can identify improper medical care. The nurse offers recommendations regarding the future treatment protocols and current cost-effective procedures available.
Medical Review Types include, but are not limited to:
- Medical Chart Review
- Medical Imaging Review
- Workers’ Compensation
- Personal Injury
- Liability
- Medical Malpractice
- Medical Negligence
- Auto Accident
- Catastrophic Injury
- Disability Review
- Plan Interpretation
- Utilization Review
- Injury/Illness Assessment
- Standard of Care
- Quality of Care
- Pharmaceutical Review
Lien Requests/Dispute Resolution
Medicare Conditional Payment Investigation and Negotiation Services
Under Medicare Secondary Payer law (42 U.S.C. § 1395y(b)), Medicare does not pay for items or services to the extent that payment has been, or may reasonably be expected to be, made through a no-fault or liability insurer or through Workers' Compensation (WC). Medicare may make a conditional payment when there is evidence that the primary plan does not pay promptly conditioned upon reimbursement when the primary plan does pay. The Benefits Coordination & Recovery Center (BCRC) is the organization responsible for recovering conditional payments when there is a settlement, judgment, award, or other payment made. When the BCRC has information concerning a potential recovery situation, it will identify the affected claims and begin recovery activities. Beneficiaries and their attorney(s) should recognize the obligation to reimburse Medicare during any settlement negotiations.
Source: http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Attorney-Services/Conditional-Payment-Information/Conditional-Payment-Information.html
Medicare Conditional Payment Verification Services
Specialty Allocations performs Medicare Conditional Payment Verification to determine if the claimant owes any conditional payments to Medicare. Once we receive proper consent forms signed by the claimant, we will identify existing conditional payments through BCRC’s estimate of the conditional payments. Our staff is both experienced and efficient when it comes to the conditional payment process. We provide frequent updates and copies of all mailed correspondence to the referral source.
Medicare Conditional Payment Negotiation Services
Specialty Allocations performs Medicare Conditional Payment Negotiation to determine if any of the conditional payments are unrelated to the pending claim. Our medical team will review the medical records in order to accurately identify the ICD-9 codes so that they can be reported to the Coordination of Benefits Contractor (COBC). In order to receive the conditional payment summary, the injuries need to be reported to COBC. Once we receive the Conditional Payment Letter we will review for improper charges, and if applicable, we will contact the BCRC in order to have the unrelated charges removed prior to settlement.
The Conditional Payment Process
Upon the receipt of the claimant’s signed releases, Specialty Allocations will submit a lien search request to the BCRC. After the request is received, a Rights and Responsibilities Letter is issued to the Medicare beneficiary and any authorized individuals listed on the Proof of Representation authorization. The Rights and Responsibilities Letter provides general information on Medicare’s rights, in addition to, the beneficiary and representative responsibilities. Within 65 days of the issuance of the Rights and Responsibilities Letter, a Conditional Payment Letter is issued. A Conditional Payment Letter provides information on the items or services that Medicare conditionally paid and what was identified as being related to the pending claim.
In some cases, items outlined in the Conditional Payment Letter are unrelated to the claim. When this occurs, Specialty Allocations’ registered nurses can review each item line by line and determine what is related to the claim and what is not. Once these items are identified, a dispute can be submitted to the BCRC. We have many success stories of significantly reducing the conditional payment amounts. We strive to the keep the Medicare conditional payment repayment obligation as low as possible, in order for the claimant to receive the most from their settlement.
Once the settlement has been finalized, the Final Settlement Detail Documents needs to be submitted to BCRC. The Final Settlement Detail Document includes the total settlement amount, itemization of costs including attorneys fees and costs, and date of settlement. BCRC will generate a Final Demand Letter when they receive the settlement information. Payment is due within 60 days of the date of the demand letter. If payment is not received within 60 days, interest will be charged from the date of the demand letter. Once payment is received, BCRC will issue a letter confirming the receipt of payment and acknowledging that the case has been closed.
*We are also able to perform lien investigations and negotiations for Medicaid and Tricare.
Social Security Query
Need Assistance with Verifying Social Security Benefits?
A Social Security Query provides information about a beneficiary’s disability and/or retirement status and benefits. The Social Security Query serves as an important planning tool for settlement purposes.
What is Social Security Disability Insurance (SSDI)?
Social Security Disability Insurance (SSDI, sometimes also abbreviated as SSD) is a Social Security program that pays monthly benefits to you if you become disabled before you reach retirement age and aren't able to work.
What is Social Security and Supplemental Security Income (SSI)?
Social Security and Supplemental Security Income (SSI) is a Federal income supplement program funded by general tax revenues (not Social Security taxes): It is designed to help aged, blind, and disabled people, who have little or no income
Specialty Allocations, Inc. can conduct a Social Security Query on your behalf in order to verify the following questions:
• Verify claimant's social security number
• Social Security eligibility status
• Have the benefits commenced?
• Number of quarters worked
• Has the claimant actually applied for Disability Benefits?
• Is the employee insured for Social Security Retirement Benefits?
• Has any offset been taken?
What is Needed to Obtain a Social Security Query?
• Completed Consent for Release of Information
• Completed Request for Social Security Disability Benefit Information
Request a Social Security Query today!
A service utilizing our team of vocational experts who accurately and objectively assess an employee's ability to safely return to work. Vocational Rehabilitation is a set of services geared towards assisting a claimant who may have a physical and/ or psychological condition. A customized and comprehensive vocational plan is developed in order to assist the claimant to overcome barriers to accessing and returning to full employment.
Vocational Testing
Vocational Rehabilitation can require feedback and testing from a range of health care professionals. Techniques/tests used for evaluation can include:
- Intelligence (IQ Testing)
- Learning styles inventory
- Dexterity Testing
- Depression and Anxiety Test
- Achievement testing of reading, language, and math skills Personality
- Aptitudes
Service Components
- Documentation of the injured worker's physical capabilities, educational background, academic skills and vocational interests.
- Chronological review of medical records and overview summary of treatment received from injury onset to present.
- Vocational testing to determine the worker's interests, achievement, aptitude, and abilities. Transferable Skills Analysis (TSA)/Work History Review to determine transferable skills to help identify potential job options.
- Labor Market Survey is performed to identify the total number of jobs available in a specific geographic location and salary ranges available for these particular positions.
- An overview of the worker's readiness and ability to return to the workforce.
- Functional status assessment completed by a physician, who notates the worker's physical limitations.
- Financial Status Review/Loss of Income provides a snapshot of the worker's expenses, loss of income, or lack of income.