By John Kane, AIC, MSCC, CMSP-F, Senior Vice President, Strategy, Ametros
You are heading to your favorite summer destination on the highway and about to pull out and pass a car. You have your blinker on and a quick check of the mirror, all clear right? Wrong, as you begin to pull out a truck blasts their horn alongside you. Many of you have experienced this feeling and the pit in your stomach.
Today’s technological advances help avoid these situations with blind side detection alerting the driver there is a car in their blind spot.
Professional administration can help injured workers avoid that pit in their stomach by properly managing the Medicare Set Aside (MSA) funds post settlement and avoiding Medicare denials and disruption of care post settlement.
Medicare has been stepping up their secondary payer authority over the years, this article will help you understand and navigate MSA administration whether you are a Medicare beneficiary, attorney, carrier or self-insured.
Medicare is Aware of Your Settlement
Medicare will be adding MSA data fields to Section 111 Total Payment Obligation to Claimant (TPOC) providing them situational awareness of both submitted and non-submit MSA’s. These new fields will allow Medicare to properly coordinate benefits following a settlement. The change will be prospective for TPOCs on or after the implementation date of April 4, 2025,
The MSA review process is voluntary with some parties choosing not to submit to The Centers for Medicare & Medicaid Services (CMS). If the parties agree not to submit, CMS may choose to deny payment for WC injury treatment following the settlement under certain conditions. CMS can require attestation of appropriate exhaustion equal to the total settlement as defined in Section 10.5.3 of the WCMSA Reference Guide, less procurement costs and paid conditional payments, before CMS will resume primary payment obligation for settled injuries, unless it is shown at the time of exhaustion, that both the initial funding of the MSA was sufficient, and utilization of MSA funds was appropriate. This will result in the claimant needing to demonstrate complete exhaustion of the net settlement amount, rather than a CMS-approved WCMSA amount.
It’s important the settling parties understand how Medicare coordinates medical post-settlement. The Medicare Administrative Contractor (MAC) processes medical bills, and they are aware of a WCMSA by an indicator (Code W) in the Common Working File (CWF), the system used to process claims. Think of the MAC as CMS radar to identify and properly coordinate who is responsible for the medical bills.
Medicare continues to take necessary enforcement actions to avoid insolvency currently projected for 2036. What this means is Medicare may not be able to cover 100% of their responsibilities for inpatient hospital care (Part A). We can all do our part in reasonably considering Medicare’s interest.
Injured workers that are soon to be or already on Medicare need to be aware of their responsibilities when settling future medical. 42 C.F.R. 411.46 addresses when to consider Medicare’s future interest on a workers’ compensation settlement. CMS looks at the MSA as a contract between the injured worker and Medicare. If the MSA reasonably considers Medicare’s interest and the injured worker can demonstrate they properly exhausted the MSA funds, Medicare should then step in as the primary payer.
Medicare is exercising greater enforcement action of the Medicare Secondary Payer (MSP) Act by denying medical bills that should be paid out of the MSA funds. This action helps preserve the financial integrity of the Medicare fund and prevent from paying claims that should be paid by another responsible party.
As CMS indicates, if an injured worker misspends the MSA funds (intentionally or unintentionally), Medicare may deny primary payment until the injured worker can demonstrate appropriate exhaustion equal to the value of the approved WCMSA. (Example: Hot tub, not covered).
CMS Expectations of MSA Funds:
- Funds are placed in a separate interest-bearing account and not commingled with other accounts.
- Treatment and prescriptions are related to the work injury and otherwise covered by Medicare. Injured workers may need to separate out billing for non-work-related conditions.
- Pay bills according to specific state fee schedules or usual and customary. Injured worker will need to understand where to go for these resources and keep apprised of any changes.
- Track and account for all expenses, treatment, dates of services and related ICD codes. This will require injured workers will need to understand what ICD codes are.
- File annual attestations for lifetime. If funds do temporarily or permanently exhaust sending in the exhaustion letter and coordinating with their physicians on coverage.
CMS “highly recommends professional administration” to injured workers resolving their future medical. If the injured worker doesn’t follow CMS guidelines for proper MSA administration, their Medicare benefits for the work-related injury could be denied without proper accounting of the exhaustion of funds.
Professional administrators provide continuation of care post-settlement. Ametros’ care advocates have the expertise to determine Medicare coverage, answer questions, and help the injured worker with their medical needs. We simplify the complex medical billing process and help injured workers save money on services through our networks. We can partner with the settling parties and help with overcoming obstacles in the settlement discussion (i.e. will the settlement funds be enough).
We encourage all parties to read, “A Study Of Medicare Treatment Denials After Settlement”.
Educating Injured Workers on the MSA’s Purpose and Responsibilities of MSA Administration
It’s important for injured workers to understand the intent of the MSA and not think they can spend the money on what they want. In the CMS memo dated 7/11/05, Medicare stated they will no longer permit claimants to request a release of unused MSA funds.
The Consent To Release Note outlined in Section 10.2 of the WCMSA Reference Guide is meant to educate the injured worker on the MSA, CMS submission process, and MSA administration. The signed consent by the injured worker allows the MSA vendor to submit and correspond with CMS to secure a determination.
Important reminder: To finalize the CMS determination, the settlement documents need to be submitted. We have noticed a trend of CMS sending out letters advising they have not received the settlement documents.
There is so much conversation at the time of settlement, it’s difficult for the injured worker to comprehend all that is going on. Understanding MSA Administration is a critical part of the discussion and will help the injured worker avoid being blindsided later by denials. Proper education will allow the injured worker to make an informed decision on whether they can self-administer or chose professional administration. If they go it alone, they should review Section 17, Account Set-up, and Administration in the WCMSA Reference Guide, WCMSA Self-Administration Toolkit and What Medicare Covers.
Place Yourself in the Shoes of the Injured Worker
If MSA administration seems like a daunting task for you, imagine the injured worker facing these responsibilities for lifetime. Settling parties can help the injured worker safely navigate the pitfalls of MSA administration by having professional administration and a team of experts as they transition off Workers’ Compensation. We encourage you to incorporate professional administration in with your settlement plan. Ametros brings peace of mind to the settling parties, educates the parties on the risks and responsibilities of MSA Administration, and breaks down barriers leading to additional settlements.
For any questions regarding CMS’ updated WCMSA reporting requirements or about ensuring compliance post-settlement with professional administration, please contact our team.
Resources:
WCMSA Reference Guide: https://www.cms.gov/files/document/wcmsa-reference-guide-version-40.pdf
WCMSA Self-Administration Toolkit: https://www.cms.gov/medicare/coordination-benefits-recovery/workers-comp-set-aside-arrangements/self-administration
Medicare Coverage: