To submit or not submit a Medicare Set-Aside for approval from the Centers for Medicare and Medicaid Services (CMS) has been a hot-button issue for several years.    While some follow a global non-submit strategy others opt to follow CMS’s guidance, where possible, considering a non-submit MSA only in specific situations.   Whether a Non-Submit MSA is utilized for settlement depends on several factors and risk tolerances, and Tower MSA Partners stands ready to analyze your claim and help you decide.

A Non-Submit MSA, sometimes called an Evidence-Based MSA, may be a reasonable alternative when the settlement does not meet CMS’s Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) review thresholds. It may seem obvious to use a Non-Submit MSA when the MSA will not be submitted to CMS, but as the methodology in drafting the Non-Submit MSA varies from CMS policy (as detailed below) some prefer to stick to CMS policy for drafting the MSA, even when not submitted.

Besides utilizing a Non-Submit MSA when CMS MSA review thresholds are not met, as the review process is voluntary, settling parties may choose a Non-Submit MSA even when the review thresholds are met.  This carries with it inherent risks in that CMS takes the position that if the funds set-aside prove insufficient “Medicare will refuse to pay for services related to the WC injury (and otherwise reimbursable by Medicare) until such expenses have exhausted the entire dollar amount of the entire WC settlement.”

A Non-Submit MSA report may have a lower allocation amount than a CMS-approved MSA because of the following features:

• Full Use of Evidence-Based Medicine – Use of evidence-based medicine, i.e., Official Disability Guidelines (ODG) or state treatment guidelines to determine reasonable care to allocate in MSA.
  • CMS inconsistently uses evidence-based medicine in its MSA review process. Using ODG and state treatment guidelines may result, for example, in a lower frequency of diagnostic testing or physical therapy visits compared to a CMS-approved MSA.
• Examining Physician Opinions Considered – Both treating and examining physician recommendations are considered in drafting the Non-Submit MSA.
  • CMS gives little consideration to examining physician opinions in its approval process.  Depending on the case, the examining physician may be in a better position to provide appropriate recommendations for current and future medical care because of their expertise and the timing of their opinion.  For example, a recent IME opinion on the necessity of surgery may be followed as opposed to a treating physician recommendation from a year ago.
• State Statutes and Regulations Followed – Fully follow state statutory, regulatory, and other legal bases for including or excluding care from the MSA.
  • While CMS approval requires an “Alternative Treatment Plan” when medical care is denied through a statutory utilization review (UR) process, a Non-Submit MSA will exclude care solely based on the UR determination.  For example, a prescription medication will not be allocated in the MSA when a UR determination supports denial.
• Claimant Statements and Agreements Considered – Consideration of claimant statements and settling party agreements concerning future medical care.
  • CMS will not usually exclude the cost of care from an MSA for a procedure or device, such as a spinal cord stimulator, based on a claimant’s statement that they will not pursue that care. Yet that statement or an agreement among the parties that certain medical care is disputed and not included in the settlement, is sufficient for a Non-Submit MSA. For example, evidence of the claimant repeatedly refusing surgery will usually result in its exclusion from the MSA.

• Professional Administration Recommended: Except for minor MSA allocations, Tower strongly recommends having a professional administrator manage the Non-Submit MSA funds. If CMS ever questions the use of these funds, proper administration will confirm they were spent properly, enabling a seamless transition to Medicare for payment if the funds run out. And, Tower proudly partners with Ametros for professional administration of all MSAs: Non-Submit MSAs and those that are CMS-approved.

Depending on the facts of the case, a Non-Submit MSA can have a significantly lower allocation than a CMS-approved MSA and still reasonably consider Medicare’s interests.  Nonetheless, using a Non-Submit MSA poses risks to the settling parties that should be fully considered and accepted prior to settlement.

Tower offers free consultations on Non-Submit MSAs. If you have any questions about these or other areas of Medicare Secondary Payer compliance, please contact Dan Anders, Chief Compliance Officer, at daniel.anders@towermsa.com or 888.331.4941.