Most Workers Compensation Medicare Set-aside (WCMSA) proposals are prepared by vendors hired by the Insurance Carrier. There are two reasons you should be skeptical of the proposal they prepare. The first is that the Carrier wants a low MSA number and the vendor wants more referrals from the Carrier, so the vendor wants to give the Carrier a low number. Think IME doctor bias. The second reason is that Medicare only requires that the last two years of medical records be submitted as part of the MSA review process. Medicare compares the records submitted to the Insurance Carrier’s payment ledger of all medical treatment expenditures for the prior two years. If the records and payment ledger match then this usually ends Medicare’s inquiry. However, what this review method does not consider, is the treatment that your client received for the work injury that was denied by the Insurance Carrier, just not paid-due to the “flavor of the week” reason bills are behind, or treatment that was mistakenly sent to private insurance to pay. These unpaid bills for treatment may result in the future projection of treatment for the work injury being significantly underestimated. If you would like more information on why taking a detailed history of your client’s medical treatment is crucial for Medicare set-aside (MSA) negotiations, read on and contact our team to learn more.
How do you ensure that your Clients receive a fairly funded MSA?
The short answer is that you need to carefully review your clients’ medical treatment and negotiate additional settlement funds to ensure that your clients receive adequate settlement dollars to cover future treatment. So before getting into a discussion of how to carefully review your clients’ medical treatment, I will answer the question: “Why do I care if the MSA funds run out, if Medicare will pay for my client’s treatment after the funds run out? The answer is that Medicare will not pay 100% of your treatment. Rather there will be copays for services and the dreaded donut hole for prescriptions. And yes, the donut hole does still exist, just in a somewhat less onerous fashion.
How do you take a detailed history of your Client’s Medical Treatment?
- Current Diagnoses/Conditions: Ask your clients what conditions and body parts they are treating for? The initial reported injuries are often overly broad or overly vague. As time goes by, some conditions may have resolved and others may have been diagnosed in greater specificity or developed later as result of the initial injury.
- Medical Providers: Ask your clients to list every medical provider they have seen in the last two years. What condition/body part did they treat? What treatment do/did they provide? How often do they see the provider?
- Surgeries/Procedures: Ask your clients about any surgeries or procedures they have had for the work injury. Will they need a revision? What follow-up care is recommended? Has any surgery or procedure been recommended but not performed? If injections were administered: did they help and are they recommended in the future?
- Other Services: Ask your clients about the following treatment that is most likely to be excluded from the MSA:
- Physical Therapy
- Chiropractic treatment
- Acupuncture
- Counseling
- Attendant Care/Home Health Aide
- Medications: Ask your clients what medications they are taking. What is the dosage? How many pills are taken a month? Does the medication help? Is the Prescriber currently weaning or switching any medication regimens? Are they taking brand or generic? If they are taking brand medication is there a reason they cannot take generic?
- DME: Ask your clients about durable medical equipment? Do they utilize a tens unit, cane, walker, braces, etc.…? When did they last receive the DME? When will it need to be replaced?
Compare your Client’s current medical treatment to the Carrier’s MSA proposal.
After completing a thorough medical history, compare the treatment your Client is currently receiving to the future treatment projected in the MSA proposal. If the proposed treatment does not seem fair at first glance, it probably isn’t.
Contact MSA Meds
MSA Meds understands that it takes specialized medical knowledge and pricing tools to develop a counterproposal to the Carrier’s MSA proposal. We also understand that ensuring an MSA is properly funded from the outset is the best way to ensure that your Clients receive the future medical treatment they need. MSA Meds is here to help you understand the best way to price excluded or undervalued treatment and negotiate additional settlement dollars to ensure that future Medicare copayments do not prevent your Clients from receiving the treatment they need. Contact MSA Meds today.
