A MSA is a tool that is used to protect Medicare’s interests concerning a Workers’ Compensation or Personal Injury settlement. Federal law requires that Medicare is always a secondary payor when there is a primary payor available. In the context of a Workers’ Compensation or Personal Injury case, the Insurance Carrier is the primary payor and may not shift the burden of future medical treatment to Medicare and the taxpayer.
A MSA is a projection of the future lifetime medical treatment needed for the work injury that would otherwise be paid for by Medicare. After settlement, this projected amount is “Set Aside” in a separate interest-bearing account. Bills for the injury are then paid from the MSA Account. If all bills are paid and all reporting is done according to Medicare’s strict rules, then Medicare will begin covering treatment for the work injury once the funds are all spent. If any funds from the MSA Account are not properly spent, Medicare will require the injured worker to deposit additional funds (from their pocket) into the MSA Account and properly spend those funds before Medicare will begin paying bills for injury-related care.
How do I determine if the MSA Proposal is a fair and reasonable projection of future treatment?
Determining a projection of future medical costs is a complicated process. The MSA proposal should be carefully reviewed and compared to the past treatment received, as well as the treatment outlined by the treating physician. This process must be done before the case is submitted to CMS for review. In fact, Medicare requires that the beneficiary approve the entire contents of the MSA proposal before it is submitted to CMS for review.
An independent evaluation of future costs should then be performed to ensure that the proposal made by the Vendor hired by the Insurance Carrier is fair and reasonable.
MSA Meds performs free reviews of Defense MSAs for eligible cases. Call us to find out how we can help ensure that your MSA Allocations are fair and reasonable.
Why should I care if the MSA is fair and reasonable if Medicare will pay bills once the funds are spent?
If MSA funds are properly spent, Medicare will begin paying bills for injury-related care when the funds are all spent. However, Medicare does pay 100% of the bill. As a general rule, Medicare will pay about 80% of bills for services such as doctor’s visits, x-rays, other tests, and physical therapy. Medications are reimbursed at variable rates depending on whether the medication is brand or generic and depending on the annual dollar threshold spent.
What is the MSA Process?
Different rules and processes apply depending on whether you have a Workers’ Compensation or Personal Injury case.
Click here to learn more about Workers’ Compensation Medicare Set-Asides (WCMSAs).
Click here to learn more about Liability or No-Fault Medicare Set-Asides (LMSAs or NFMSAs).
Click here to learn more about Non-Submit and Evidence-Based MSAs (EBMSAs).
Is there an Appeals Process for MSAs?
While there is no formal process to appeal a MSA Determination by CMS, there are processes to request a Re-Review or Amended MSA Determination. In addition, Medicare’s actual denial of payment for treatment may be appealed in a 5 step process.
Click here to learn more about the Medicare Appeals Process.
