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.
