Nothing can stall settlement faster than a Medicare Set-Aside (MSA) that includes an unnecessary or unwanted medical procedure. Procedures like surgeries, spinal cord stimulators (SCSs), and intrathecal pain pumps significantly raise the costs of MSA allocations. Fortunately, Tower’s client partners have access to our complimentary Physician Follow-up service that Save on MSAs.

In a recent case, this service successfully removed a costly SCS from the MSA, resulting in a savings of $132,232.

Challenges with SCS Trial Inclusion in MSAs: Addressing Worker Reluctance and CMS Requirements

A worker who had suffered a low back injury was advised by his neurosurgeon and pain management physician to consider an SCS trial. A review of treatment records showed that the injured worker was very anxious about the procedure, and a psychological evaluation revealed a diagnosis of major depressive disorder.

Despite the worker’s reluctance to undergo the procedure, CMS will include it in the MSA, assuming that the worker may change their mind. Tower drafted an initial MSA to include the SCS for a total allocation of $157,500.

Successfully Removing SCS from MSA with Physician Statements: Tower’s Approach

The injured worker’s resistance to the procedure and results of the psych evaluation indicated he would not be a suitable candidate for an SCS. Therefore, we recommended that our Physician Follow-up service obtain statements from both physicians that confirmed the SCS is no longer part of the treatment plan. (If only one physician had provided a statement, CMS would likely keep the SCS in the MSA).

After client approval, in compliance with this jurisdiction’s regulations, Tower notified the plaintiff’s attorney of our intention to communicate with the injured worker’s providers. We then contacted the neurosurgeon and pain management specialist and provided them drafts of physician statements that confirmed the SCS is no longer a treatment option.

While it took several weeks of persistent follow-up with the physicians’ offices, Tower successfully obtained both signed statements.

Efficient MSA Revision: Tower Achieves Significant Cost Reduction and Quick CMS Approval

Tower revised the MSA down from $157,500 to $25,268 and submitted it to CMS. CMS approved the MSA within two weeks for the proposed amount.

In response, Tower’s client said, “Great job, Tower! I am so thankful for our partnership and truly appreciate your hard work and persistence. $132k in savings!!! Woohoo!”

The defense attorney said, “you guys work some real magic here, bravo!”

It’s more methodology than magic, but we often find opportunities to reduce the allocation or mitigate potential increases from CMS review when we draft an MSA. Vague references to potential future procedures mean these costs will be included in the MSA. CMS’s exacting review process requires explicit confirmation of the last dates of service and ongoing treatment and medications.

At no extra charge, Tower contacts physicians, clarifies treatment, drafts physician statements, and obtains medical providers’ signatures to document dates of treatment and ongoing and future medical care. This service paves the way to quick CMS MSA approval and mitigates the potential for unexpected increases.

To learn more about our Physician Follow-up service, please get in touch with Hany Abdelsayed at 888.331.4941 or hany.abdelsayed@towermsa.com.