Non-Submit Medicare Set-Aside

Projection of future medical care built upon evidence-based medicine and state statutes

A Non-Submit MSA may be appropriate in situations where the settlement does not meet the CMS WCMSA review thresholds, or the settling parties have decided not to participate in the voluntary CMS MSA review process. This type of MSA report will typically be a lower allocation amount than a CMS-approved MSA as a result of the following features:

  • Use of evidence-based medicine to determine reasonable care to allocate in MSA.
    • Example: CMS inconsistently utilizes evidence-based medicine in its MSA review process. By consistently utilizing evidence-based medicine the frequency of such allocated treatments, i.e. diagnostic testing, is typically lower in the Non-Submit MSA.
  • Treating and examining physician recommendations considered within totality of course of medical care and time period in which given.
    • Example: An older recommendation from a treating physician for surgical intervention may be supplanted by a more recent opinion from an examining physician which does not recommend surgery.
  • Fully considers state statutory, regulatory and other legal bases for either including or excluding care from the MSA.
    • Example: While as part of the MSA review process CMS requires what is called an “Alternative Treatment Plan” where medical care is denied through a statutory utilization review process, a Non-Submit MSA will exclude care solely based upon the UR determination.
  • Consideration of claimant statements and settling party agreements concerning future medical care.
    • Example: Claimant statement asserting he or she will not pursue a certain course of care, i.e. spinal cord stimulator, will normally be sufficient to exclude such care from a Non-Submit MSA.

Any questions or concerns regarding the Non-Submit MSA, including whether this type of report is appropriate for your settlement, can be discussed through a Tower MSA Partners free consultation (See form on right to request consultation). If you are ready to refer a matter for a Non-Submit MSA follow this link to a referral form (Indicate “Non-Submit MSA” in the Notes section of the referral form).

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