$1 Million Saved with Physician Peer Review

December 4, 2025

In Tower MSA Partners’ previous post, we explored “How Pre-MSA Triage Prevented $774k In Unnecessary Costs” by diagnosing issues before submission. This month, we move from prevention to precision. Through a comprehensive Physician Peer Review, Tower MSA Partners helped a client reduce projected MSA costs by more than $1 million, reinforcing how clinical oversight transforms both financial and compliance outcomes.

Identifying the Problem

The claim involved a long-term pain management case where the claimant had been prescribed multiple overlapping therapies and high-cost medications for years. On paper, everything appeared compliant, but Tower’s experienced analysts recognized red flags. The medications had not been re-evaluated for clinical necessity, and several treatments were duplicative or no longer consistent with current medical standards.

Left unchecked, the proposed MSA would have locked the payer into unnecessary costs for the claimant’s lifetime medical care. Beyond the financial impact, the payer also faced potential CMS scrutiny for including treatments without supporting clinical documentation. This is where Tower MSA Partners’ layered review process stepped in.

The Physician Peer Review Solution

Tower’s team initiated an independent Physician Peer Review, assigning the case to a licensed physician with expertise in pain management. The reviewer conducted a full analysis of the medical history, treatment progress, and prescription patterns. This deep clinical evaluation uncovered that several medications could be tapered or replaced with safer and lower-cost alternatives.

For example, the claimant was taking a combination of opioid medications that exceeded current best practice guidelines. The reviewing physician documented a detailed rationale for modification, providing evidence-based recommendations that were not only medically sound but also compliant with CMS expectations.

Once incorporated into the revised MSA, these adjustments reduced projected costs by more than $1 million while maintaining patient safety and treatment continuity.

Collaboration and Communication

One of Tower MSA Partners’ key strengths lies in its ability to bridge communication between medical reviewers, claims professionals, and legal teams. Rather than simply returning a report, Tower’s clinical experts walked the client through each recommendation, explaining how and why changes were appropriate. This transparency ensured that the payer, the defense attorney, and the treating physician were aligned before submission.

The final MSA reflected current medical necessity and included detailed documentation supporting each change. When presented to CMS, the submission received prompt approval with no development requests — a testament to the thoroughness of Tower’s process.

Why Oversight Makes the Difference

In MSA management, accuracy is everything. A single unchecked treatment plan can inflate costs by hundreds of thousands of dollars. Physician peer review adds a layer of expert validation that standard file reviews simply cannot provide. By ensuring that each projected medical service is both necessary and properly justified, Tower protects clients from avoidable financial and compliance risks.

This case demonstrates the tangible value of pairing clinical and administrative expertise. It also reinforces a key truth in the MSA industry: compliance and savings are not competing goals. When handled correctly, one strengthens the other.

Lessons Learned

Medical oversight pays off. Involving a physician reviewer early or mid-process can uncover inefficiencies that purely administrative reviews miss.
Documentation drives approval. Every modification included detailed clinical support, making CMS approval faster and more predictable.
Collaboration builds trust. Transparent communication between Tower, the client, and treating providers eliminated resistance and ensured everyone understood the reasoning behind the changes.
Savings reflect strategy. The $1 million reduction was not luck, it was the result of structured review protocols, experienced medical oversight, and Tower’s culture of precision.

Results That Reflect Expertise

Beyond the financial win, this case underscored Tower MSA Partners’ reputation for pairing clinical insight with regulatory mastery. The client achieved measurable ROI, CMS compliance, and peace of mind knowing that future medical allocations were realistic, defensible, and supported by clinical data.

Each peer review conducted by Tower is more than a medical check — it is a safeguard for payers, claimants, and settlements. This case serves as another example of how Tower delivers consistent, evidence-based results that protect both cost and care quality.

FAQs

What is a Physician Peer Review in MSA?
It is an independent medical evaluation that confirms treatment plans and medications in an MSA are clinically justified and aligned with CMS guidelines.

How does Peer Review reduce MSA costs?
By identifying unnecessary or outdated treatments and offering safer, evidence-based alternatives, peer review reduces total medical cost projections without compromising care.

Does CMS recognize Peer Reviews?
It’s important to combine the peer review with clinical oversight to document the changes to the treatment plan and medication regimen, which CMS will recognize.

When should an MSA include a Peer Review?
Any time a claim involves long-term treatment or high medication costs, a peer review should be performed before submission.

Why Case Studies Matter: Real-World Proof of MSA Savings

October 7, 2025

Image of Tower MSA Partners Why Case Studies Matter series: Blog 1 Real-World Proof of MSA Cost Savings.

While Medicare Set-Asides (MSAs) are essential for compliance in certain workers’ compensation settlements, they can also lead to inflated costs if not carefully managed. Without proper oversight, unnecessary treatments, duplicate services, or overly conservative assumptions can cause MSA totals to rise dramatically. These inflated amounts not only delay settlements but also tie up resources that could be better used elsewhere.

At Tower MSA Partners, we help insurers, self-insured employers, and third-party administrators (TPAs) navigate this complex process with precision and cost control, ensuring settlements are compliant, efficient, and fair.

This kickoff blog launches a 12-month series of real-world case studies demonstrating how proactive strategies, clinical expertise, and deep regulatory knowledge deliver measurable savings and smoother claim resolutions.

Common MSA Challenges

For many claims professionals, MSAs can feel like a “black box.” The process often seems like paperwork sent off to CMS, followed by a waiting game for approval. This lack of transparency can lead to missed opportunities for cost savings and compliance improvements.

Here are a few recurring challenges we see: – Unnecessary treatments or duplicate costs included in MSA submissions – – inconsistent and contradictory treatment patterns – Lack of early intervention to address treatment plans before they escalate – Missed opportunities to optimize claims for both cost control and compliance

These issues affect everyone involved—from injured workers to payers. Through detailed case studies, this series will show how a strategic, proactive approach prevents these challenges and leads to better settlement outcomes.

Real Savings, Real Impact

The strength of this series is in real numbers and real results. In the coming months, we’ll highlight outcomes such as: – $774,000 saved by identifying and resolving issues before MSA submission – $1 million saved through a physician peer review that corrected unnecessary treatment recommendations – $98,000 saved with a second-opinion MSA review before finalizing settlement

These results represent actual cases handled by Tower MSA Partners. They demonstrate how compliance and cost containment can work together to protect Medicare’s interests while avoiding overfunding.

Why Case Studies Matter

Every claim is unique, yet the challenges surrounding MSAs are surprisingly consistent across the industry. Factors like rising medical costs, evolving CMS guidelines, and the push to close claims quickly create a complex balancing act.

Through these case studies, Tower MSA Partners aims to: – Improve the quality and defensibility of MSA submissions – Speed up settlements by eliminating preventable delays – Lower claim costs without compromising care – Provide clarity and confidence for claims professionals handling complex cases

When payers understand why certain costs are included and how they can be managed, they make smarter, more informed decisions that benefit their organization and the injured workers they serve.

What’s Ahead in the Series

Each month, we’ll release new content focusing on a specific area of MSA management, including: – Early Intervention Strategies – Preventing inflated costs before an MSA is created – Physician Peer Review – Validating treatment plans and prescriptions – Compliance Best Practices – Reducing the risk of CMS penalties and rejections – Ongoing Claim Management – Preventing cost creep over time – Legacy Claim Resolution – Closing backlogged claims to free reserves and improve efficiency – Case Optimization and Review – Streamlining processes to improve accuracy and outcomes

The series will conclude with a Top 10 Lessons Learned wrap-up blog summarizing a year’s worth of data and insights for claims professionals and legal teams.

The Takeaway

MSAs don’t have to be overwhelming or overly expensive. With the right approach, organizations can achieve compliance, control costs, and resolve claims efficiently. This series will provide real-world proof of how Tower MSA Partners helps clients reach these goals, step by step.

Stay tuned for our first in-depth case study, where we’ll explore how early intervention prevented nearly $800,000 in unnecessary costs and paved the way for a smooth, compliant settlement.

Frequently Asked Questions

What causes Medicare Set-Asides to become inflated?
Inflated MSAs often come from unnecessary treatments, duplicate services, outdated prescriptions, or conservative medical assumptions that were never updated.

Why do MSA case studies matter?
They show real savings and real outcomes so payers can understand how proactive MSA strategies improve accuracy, compliance, and cost control.

What are the most common challenges in MSA preparation?
Unnecessary care, inconsistent documentation, lack of early intervention, and missed opportunities to correct treatment plans.

How does Tower MSA Partners reduce MSA costs?
Through early clinical review, pharmacy analysis, physician communication, and regulatory expertise that remove unnecessary or inaccurate costs.

Who benefits from proactive MSA management?
Claims adjusters, TPAs, self-insured employers, risk managers, and injured workers all benefit through faster, cleaner, and more cost-effective settlements.

How much can proactive MSA strategies save?
Savings vary, but real cases show reductions such as $774,000 saved before MSA submission and $1 million saved via physician peer review.

Does improving MSA accuracy slow down settlements?
No. Addressing medical and documentation issues early creates smoother CMS approvals and eliminates preventable delays.

What topics will this 12-month case study series cover?
Early intervention, physician peer review, compliance best practices, legacy claim resolution, and prevention of medical cost creep.

How does this series help claims professionals?
It provides transparent examples, clearer processes, and actionable steps for improving accuracy, compliance, and settlement outcomes.

Does My Settlement Qualify for a Zero MSA?

August 5, 2025

As the final post in our Do I Need an MSA? series, we turn to $0 MSAs. While CMS no longer reviews and approves $0 MSAs, they remain a legitimate and strategic option in specific settlement scenarios. And when a $0 MSA is appropriate, the parties can settle with the confidence that Medicare’s interests are protected as well as the injured workers’ access to Medicare to pay for treatment.

But when exactly is a $0 MSA appropriate?

Let’s explore.

What Is a $0 MSA?

A $0 Medicare Set-Aside (MSA) allocates no funds for future Medicare-covered medical expenses related to the claimed workers’ compensation injury. In short, it means the settling parties believe either that the denied nature of the claim means Medicare is primary for future medical or, if an accepted claim, that there is no further need for injury-related treatment or medications.

While this sounds simple, CMS requires specific criteria to be met and supported by documentation to ensure that Medicare’s interests are still being considered appropriately. After all, even a $0 allocation must be defensible.

When Is a $0 MSA Appropriate?

The Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide, Section 4.2, outlines the situations in which a $0 MSA is appropriate. Below are the scenarios:

The Claim Is Denied and No Medical or Indemnity Payments Have Been Made

This is the most straightforward situation:

The insurer has not paid any medical or indemnity benefits (except for investigational purposes) prior to settlement,
The claim remains fully denied, and
The settlement does not allocate funds for future or past medical.

Denied Claim with Prior Payments

If some medical payments were made early in the life of the claim, but the carrier later issued a formal denial and maintained it throughout, a $0 MSA may still be possible. Criteria to be met:

The claim was denied,
Denial was within state statutory timeframe allowed to pay without prejudice, and
The settlement does not allocate funds for future or past medicals.

Court Decision on Compensability of Claim or Ongoing Medical

If a court, commission or board finds after a hearing on their merits that either the claim is not compensable or that the employer does not owe additional medical or indemnity benefits, then a $0 MSA is applicable. The payer needs to ensure that they abide by such a decision in terms of not paying for additional medical or indemnity short of a compromise settlement.

Injury-related Medical Condition Has Resolved

In some cases, the injured worker may have recovered fully, no longer receives treatment, and no further Medicare-covered services are anticipated. Even if the claim was accepted at one time, a $0 MSA may be appropriate if:

There is sufficient medical evidence to support full recovery,
The treating provider documents that no future treatment is required,

CMS Policy Change: $0 MSA Submissions No Longer Reviewed After July 17, 2025

As noted above, effective July 17, 2025, CMS no longer reviews $0 MSA submissions. This change reflects a shift in resource prioritization: CMS sees limited value in reviewing MSAs that allocate no funds to future medical.

However, this does not remove the obligation to protect Medicare’s interests. Instead, the burden falls more squarely on the settling parties to:

Evaluate whether a $0 allocation is appropriate,
Document the justification thoroughly, and
Retain that documentation as evidence of compliance.

At Tower MSA Partners, we anticipate this shift will increase the importance of clear documentation and expert evaluation. Without CMS review, you need a partner who can help you build a strong, defensible case for a $0 MSA.

Documentation Checklist: Building a Defensible $0 MSA

To support a $0 allocation, especially in a post-CMS review environment, be sure to compile the following:

Denial Letter (for a denied claim) – Official claim denial from the payer
Claim Payment History – Showing medical, indemnity and expense payments
Medical Records (for an accepted claim) – Indicating no ongoing or anticipated treatment
Legal Documents – Any court orders or other legal documents pertinent to the denial or need for ongoing and future injury-related medical care.
Physician Statement – If applicable, confirming no future medical care is necessary

This documentation can be provided for Tower to review and prepare a report that confirms the case meets CMS $0 MSA criteria.

How Tower MSA Partners Can Help

Tower’s experienced team brings together clinical, legal, and claims expertise to:

Evaluate whether a $0 MSA is appropriate,
Provide recommendations to obtain a valid $0 MSA,
Prepare a clear and defensible report, and
Help to explain CMS’s $0 MSA criteria to settling parties and assist with appropriate settlement language.

Final Thoughts: The Power of Zero—When Used Wisely

A $0 MSA can be a powerful tool in the settlement process, helping to close claims quickly and reduce costs. But like all compliance strategies, it must be used wisely.

As CMS steps back from $0 MSA reviews, the responsibility for Medicare compliance falls squarely on the parties involved. Tower MSA Partners is here to guide you.

Ready to Evaluate a Zero MSA?

Let us help you determine whether your settlement qualifies for a $0 MSA, and make sure it’s documented the right way.

Contact Tower MSA Partners today to schedule a consultation.

Decoding CMS Development Letters: Prevention, Trends, and Effective Responses

July 2, 2025

Avoid CMS Development Letter Delays: Learn How in Our Upcoming Webinar

The Centers for Medicare & Medicaid Services (CMS) continues to issue an increasing number of CMS Development Letters following Medicare Set-Aside (MSA) submissions, and not all of them make sense. While some requests are warranted, many appear unnecessary, resulting in delays, frustration, and additional work for claims teams.

At Tower MSA Partners, our strategy has always been to prevent Development Letters before they happen. Even with meticulous planning, CMS sometimes requests additional documentation to finalize its review. That’s why it’s critical to know how to anticipate, address, and respond to these letters when they arrive.

Join us for a live webinar on July 23, 2025, at 2:00 p.m. ET as Tower’s Chief Compliance Officer, Dan Anders, and CMS Submission & MSP Compliance Manager, Brittany Wilkerson, break down:

- - The most common CMS Development Letter requests you can expect
  - Unusual and emerging requests CMS is making
  - Proactive steps to prevent Development Letters
  - How to partner with Tower to avoid or quickly resolve these requests

You’ll also have the opportunity to submit questions in advance to be answered live during the session.

Don’t let CMS Development Letters slow down your settlement process.

Register

Self vs. Professional MSA Administration: Which Is Right for the Injured Worker?

June 25, 2025

Comparing Options for Managing Medicare Set-Aside Funds Post-Settlement

When a workers’ compensation claim settles and includes a Medicare Set-Aside (MSA), that’s not the end of the story, it’s the beginning of a new responsibility for the injured worker. That responsibility? Administering the MSA in compliance with the Centers for Medicare & Medicaid Services (CMS) guidelines.

There are two options for handling this responsibility: self-administration or professional administration. Each comes with its own benefits and risks. So, which is right for the injured worker? Let’s break it down.

What Is MSA Administration?

MSA administration refers to how the injured worker manages and spends the money allocated for future medical care related to their injury. These funds must only be used for Medicare-covered expenses that are injury-related, and spending must be carefully tracked in case CMS ever audits the account.

Failing to comply with these rules can lead to serious consequences as Medicare may refuse to pay for injury-related care once the MSA funds are exhausted, leaving the injured worker on the hook.

Option 1: Self-Administration

With self-administration, the injured worker is responsible for managing their own MSA funds. This includes:

Setting up a separate interest-bearing account
Paying for medical treatments and prescriptions out of the MSA account
Ensuring payments are only for Medicare-eligible, injury-related services
Tracking all expenditures and retaining documentation
Reporting annual spending to CMS

Pros:

Full control over how and when funds are used
No administrative fees
May be appealing for workers who are detail-oriented or have experience managing finances

Cons:

Requires a thorough understanding of CMS guidelines
High risk of non-compliance, even with good intentions
No built-in advocacy or support in the event of disputes with providers or Medicare
Can become overwhelming, especially for those dealing with complex or ongoing care

Option 2: Professional Administration

Professional administration means a third-party administrator manages the MSA on the injured worker’s behalf. This service typically includes:

Establishing and maintaining the MSA account
Processing and paying medical bills and prescriptions
Ensuring all expenditures are CMS-compliant
Annual reporting to CMS
Providing injured workers with support and transparency

Pros:

Ensures CMS compliance and minimizes risk of Medicare denial
Reduces stress and complexity for the injured worker
Access to medical cost containment strategies, such as network discounts
Professional tracking, reporting, and auditing protections
Peace of mind for both the injured worker and the settling parties

Cons:

Typically involves a one-time setup fee and annual service fees (although this is usually paid by the employer or insurer at the time of settlement)
Less direct control over funds

Making the Right Choice

The right choice depends on the injured worker’s capabilities, preferences, and the complexity of their care. Here are a few considerations:

Complexity of Care: If the injured worker has ongoing treatments, expensive prescriptions, or multiple providers, professional administration can prevent missteps.
Comfort with Financial Management: Self-administration may be feasible for someone confident in managing money and navigating healthcare systems.
Compliance Risk Tolerance: Professional administration significantly lowers the risk of non-compliance and CMS scrutiny.
Support Needs: Injured workers often appreciate having an advocate who can assist with billing issues and provider coordination.

A Partner in Post-Settlement Success

At Tower MSA Partners, we work closely with injured workers, carriers, and attorneys to evaluate the best administration path for each case. When professional administration is chosen, we partner with Ametros to provide this service.

Ensuring compliance and protecting the long-term well-being of the injured worker doesn’t stop when the claim settles. Choosing the right MSA administration option is one of the most important settlement decisions, one that can make all the difference in the quality of care and peace of mind.

Stay tuned for our next article in the series on $0 MSAs.

What Are Some Common MSA Challenges?

June 10, 2025

Fifth Installment in our Tower MSA Partners Series

Avoiding the Pitfalls That Can Derail Settlement Success

When it comes to resolving workers’ compensation claims involving future medical exposure, Medicare Set-Asides (MSAs) are a critical component, but they’re not without challenges. Whether you’re preparing an MSA for submission to the Centers for Medicare & Medicaid Services (CMS) or managing one post-settlement, there are several recurring pain points that can complicate and delay the settlement process. In this post, we explore the most common MSA challenges and share strategies to address them proactively.

CMS Development Requests

Perhaps the most frustrating challenge for claims professionals is when an MSA submitted to CMS results in a request for additional information. Common reasons include:

Missing or outdated medical records
Clarification of accepted and denied body parts and conditions
DME records not provided
Need for personal prescription history

Each delay may add weeks, even months, to the settlement timeline. Working with a partner that understands CMS submission requirements inside and out, and stays ahead of guideline changes, can minimize these setbacks.

At Tower MSA Partners, our Physician Follow-up service is key to development letter avoidance. At no cost to our client partners, Tower will contact the treating physician to confirm matters such as the last date of service and ongoing treatment and medications. By doing so, we ensure documentation is complete, consistent, and aligned with CMS’s expectations before submission.

Overfunded MSAs Due to Inaccurate Cost Projections

Another issue is inflated MSAs, which can stall settlements or make them financially unworkable. MSAs are meant to reflect reasonable and necessary future medical costs, but they can become overfunded when:

Treating physicians list aggressive or non-evidence-based treatment plans
High-cost medications are projected indefinitely, even if alternatives exist
Outdated surgical recommendations are included
Medicare pricing is not properly applied, or generic equivalents are overlooked

To avoid this, the MSA projection must go hand-in-hand with medical intervention. That includes communicating with providers to clarify treatment intent, securing appropriate clarifications, and exploring the use of evidence-based guidelines. Tower’s clinical team excels in this area, often reducing MSA costs significantly through strategic interventions and updated treatment plans.

Navigating the Gray Areas of Compliance

MSAs are meant to protect Medicare’s interests, but interpretation of compliance can vary. For example:

When is a $0 MSA appropriate?
Is CMS submission required for every settlement?
Is an MSA re-review or an amended review appropriate?

Navigating these gray areas requires expertise in CMS’s evolving guidelines, as well as a solid understanding of case law and best practices. Missteps, such as underfunding or improper spending, can leave all parties exposed to future liability.

Tower MSA helps payers and attorneys make informed, case-by-case decisions on whether submission is warranted, whether re-review is advantageous, and if a $0 MSA is feasible.

Timing and Settlement Coordination

MSAs don’t exist in a vacuum. Delays in obtaining MSA approvals can impact the broader settlement process, especially when dealing with multi-party negotiations, liens, or Social Security Disability applications. If the MSA process isn’t started early enough or coordinated with other settlement activities, it becomes a bottleneck.

That’s why early intervention is key. At Tower, we help claims professionals identify MSA candidates early in the claim lifecycle and integrate MSA timelines into the overall resolution strategy.

Legacy Claims and “Old Dogs”

Some of the most complex challenges come from aging claims, especially those with inconsistent treatment history, outdated care plans, or decades-old documentation. These “old dog” claims often present inaccurate MSAs or complex settlement dynamics.

In these cases, seeking an Amended Review (where CMS previously approved an MSA on the claim) or engaging Tower’s clinical team to reassess and clarify treatment plans can be game-changing. We’ve helped clients reduce legacy claim MSAs by hundreds of thousands of dollars through re-review, updated records, and provider outreach.

Proactive Partnership = Smoother Settlements

Ultimately, many MSA challenges stem from incomplete documentation, lack of clarity, or missed opportunities for cost mitigation. A proactive, strategic approach, combined with deep CMS expertise, can resolve these challenges before they become roadblocks.

Tower MSA Partners doesn’t just provide MSA compliance, we provide settlement support that moves claims forward. From early identification and medical cost mitigation to CMS submission, we ensure your MSAs support, not stall, your claim closure goals.

Stay tuned for our next article in the series, “Self vs. Professional MSA Administration: Which Is Right for the Injured Worker?”

What’s Included in a Medicare Set-Aside (MSA)?

May 13, 2025

Tower MSA Partners presents What’s included in an MSA with a button that says find out.

Fourth Installment in our Tower MSA Partners Series

In our previous posts, we introduced the fundamentals of Medicare Set-Asides (MSAs), explained how they work, and outlined when an MSA is necessary. Now, we turn to the next important question: what exactly is included in an MSA?

At Tower MSA Partners, we ensure that every MSA is carefully developed to provide for the injured worker’s future medical care needs while protecting Medicare’s interests. In this article, we break down the typical components of an MSA allocation.

Future Medical Costs

The core of any MSA is the projection of future medical expenses related to the work injury or illness that Medicare would otherwise cover. These expenses include, but are not limited to:

Physician visits (primary care and specialists)
Hospitalizations
Physical therapy
Diagnostic testing (X-rays, MRIs, CT scans)
Durable Medical Equipment (DME), such as wheelchairs or prosthetics
Home health care services, if related to the injury
Surgical procedures

Each projected cost is based on the injured worker’s medical history, current treatment plan, and anticipated future needs as determined through a comprehensive medical record review.

It is important to remember that CMS relies on the notes and opinions of the treating physician(s). Examining physicians, such as IMEs, PQMEs, AMEs, and the like, do not carry weight with CMS. Furthermore, statements from injured workers indicating that they do not plan to pursue a certain course of treatment, such as a spinal cord stimulator, will not be considered by CMS if a treating physician continues to recommend it as a treatment option.

Prescription Medications

In addition to medical services, the MSA must also allocate funds for prescription medications related to the injury. These include:

Ongoing maintenance drugs (such as pain management medications)
Antibiotics for recurring infections tied to the injury
Future prescriptions based on ongoing treatment needs

It’s important that the medications included in the MSA are tied directly to the work-related condition and are likely to be needed based on current and reasonably foreseeable medical standards.

Treatment Trends and Cost Mitigation

Accurately projecting future care is essential to ensuring that the MSA is sufficient but not overinflated. This means factoring in:

Discontinuation of treatments that are no longer medically necessary
Weaning off medications (such as opioids) where clinically appropriate
Updates or clarifications from treating physicians to mitigate outdated or unnecessary ongoing care assumptions

At Tower, we work closely with treating providers to clarify treatment plans and identify opportunities to right-size the MSA appropriately.

CMS Submission Documentation Requirements

If the MSA is submitted to the Centers for Medicare & Medicaid Services (CMS) for review and approval, there are specific documentation requirements:

Submission of all relevant medical and pharmacy records for the most recent two years for each settling body part or condition
The Medicare Set-Aside Report
Claim payment history
Claim prescription drug history
Claimant executed Consent to Release form
Clear explanation of how the MSA will be funded (lump sum vs. annuity) and administered (self-administered or professionally administered)
If applicable, court orders, denial letters and depositions

Tower strives to provide a straightforward allocation for future medical care supported by the necessary treatment records and pharmacy history. In doing so, we avoid CMS development letters and expedite the settlement process for the parties.

Conclusion

A properly developed Medicare Set-Aside includes a detailed projection of future medical costs, related prescription medications, and compliance with CMS submission requirements. Ensuring these elements are accurately captured is critical to protecting Medicare’s interests and the injured worker’s access to necessary care.

At Tower MSA Partners, our expert team builds MSAs that are precise, defensible, and compliant, helping you navigate settlements with confidence.

Stay tuned for our next blog in the series, where we will explore “What are Some Common MSA Challenges? “

Need assistance with your Medicare Set-Aside allocations? Contact Tower MSA Partners today.

How Do I Know If I Need a Medicare Set-Aside?

April 22, 2025

Tower MSA Partners banner with copy that reads “How do I know if I need an MSA” with a button that says find out with papers, medication, money, a magnifying glass, and EKG results.

When planning a settlement with a Medicare beneficiary injured worker or someone close to becoming a Medicare beneficiary, ensuring that the burden of future medical care is not shifted to Medicare is paramount. In our previous posts, we introduced the fundamentals of Medicare Set-Asides (MSAs) and detailed how they work within workers’ compensation claims. Now, we take a closer look at the key factors, such as projected medical costs, specific monetary thresholds, and special circumstances, that determine whether an MSA is required.

Refining the Decision: Beyond the Basics

While earlier blogs explained the overall structure and regulatory importance of MSAs, this post focuses on the critical evaluation of each case. Determining whether an MSA is necessary hinges on two primary considerations: Medicare eligibility and settlement size. At the same time, there are instances where, after a thorough review, a $0 MSA is both appropriate and legally supported.

Medicare Eligibility: Immediate vs. Imminent

A starting point to determine the need for an MSA is whether the injured worker is or is not Medicare eligible.

Immediate Eligibility:
For injured workers who are already covered by Medicare, any settlement must include an MSA (CMS now requires the payer to report the MSA amount at the time of settlement), whether that is a $0 allocation or an earmark of funds exclusively for care that Medicare would otherwise cover.
Imminent Eligibility:
When a claimant is not Medicare eligible but is expected to qualify for Medicare within the next 30 months due to being 62 ½ or older or having applied for or receiving Social Security Disability Insurance (SSDI) benefits, an MSA should also be a consideration – especially when there is a clear need for long-term future medical care.

Settlement Size: Monetary Thresholds as a Trigger

For many years, CMS has had in place monetary thresholds for when they will review and approve an MSA:

For Medicare-eligible individuals, settlements exceeding $25,000 allow for a CMS-approved MSA.
For those approaching Medicare eligibility, settlements where anticipated future healthcare costs exceed $250,000 allow for a CMS-approved MSA.

Whether an MSA is submitted to CMS or not, most settling parties will include an MSA in the settlement if these triggers are met. The situation becomes more complicated when the monetary thresholds are not met.

For example, consider a Medicare-eligible claimant where the settlement will be $15,000. As noted earlier, CMS requires you to report an MSA amount. As such, either a $0 or a specific MSA dollar amount will need to be included in the settlement.

Now say you have a $100,000 settlement involving a 63-year-old claimant who is not a Medicare beneficiary, the injured worker’s specific medical history and need for long-term medical care should be considered in determining whether an MSA is appropriate.

$0 MSA

In many cases, reserving funds for future medical care is necessary, yet thorough medical and legal evaluations sometimes support a $0 MSA. Recent policy changes have further clarified this area. We will cover this in more detail in a future post.

MSA Decision Best Practices

Here are some targeted best practices for determining whether an MSA is necessary:

Identify the Medicare status of the claimant.

If you are a payer, then you have access to the Section 111 reporting information on whether the claimant is a Medicare beneficiary. If not a payer, then make an inquiry to the claimant as to their Medicare status. If not a Medicare beneficiary, then are Medicare’s interests nonetheless implicated based on their age or having applied for SSDI benefits?
Follow Tower’s “Do I Need a Workers’ Compensation Medicare Set-Aside (WCMSA)” decision tree to determine whether an MSA is appropriate.

Settlement Value and the MSA

CMS MSA Submission Approval:
While an MSA may be a consideration in any settlement involving a Medicare beneficiary claimant or one close to Medicare eligibility, depending on settlement value, CMS approval of the MSA can be obtained.
Non-CMS Approved MSAs:
An MSA should still be considered when CMS MSA approval cannot obtained. This is especially true when the claimant is a Medicare beneficiary, even when the settlement is $25K or less and where the claimant has applied for or is receiving SSDI, even when the settlement is $250K or less.

Engage Specialized Expertise

Consult Compliance Experts:
Collaborate with attorneys, or experts like Tower MSA Partners, specializing in Medicare Set-Asides to ensure that every decision is compliant with CMS and state guidelines.
Stay Updated:
Keep abreast of any regulatory changes, such as the recent CMS update eliminating $0 MSA reviews, to ensure ongoing compliance.

Enhance Stakeholder Communication

Internal Alignment:
Ensure that all team members, from legal advisors to claims adjusters, understand the criteria for establishing an MSA.
Client Transparency:
Clearly explain to injured workers how their settlement is structured and the rationale behind inclusion of an MSA in settlement, ensuring they understand the implications for their future care.

Conclusion

Determining whether a Medicare Set-Aside is necessary involves a careful analysis of Medicare eligibility and settlement value. An MSA may be needed in both situations where CMS approval and can and cannot be obtained. In either case, the goal for the settling parties is to close out medical with the reasonable assurance that they have not shifted the burden of future medical care to the Medicare program. In most cases this will involve some type of allocation for future medical care while in some a $0 MSA may be the right solution.

For personalized guidance on evaluating your case or determining the most appropriate MSA strategy, Tower MSA Partners is here to help. Contact our team to navigate the complexities of Medicare Set-Asides with confidence.

Stay tuned for the next article in our series on “What is Included in an MSA?”

MSA 101: What is an Medicare Set-Aside?

March 5, 2025

This is the first in a series of articles on the basics of Medicare Set-Asides (MSA) that Tower will be releasing in the coming weeks. For those familiar with MSAs, think of this as a refresher on what an MSA is, how it operates, what it contains, and when you should use one. If you are new to MSAs or have limited experience with them, consider this as your MSA 101 course. Enjoy!

In the world of workers’ compensation, ensuring that Medicare’s interests are protected is a critical component of settlement negotiations. This is where an MSA comes into play. If you’ve ever wondered what an MSA is, why it’s necessary, and how it impacts claim settlements, this article will provide you with a foundational understanding.

What is a Medicare Set-Aside (MSA)?

A Medicare Set-Aside (MSA) is an arrangement that allocates a portion of a workers’ compensation settlement to cover future medical expenses related to the work-related injury, ensuring that Medicare does not pay for treatment that should be covered by the settlement. This amount is “set aside” in a designated account and is used exclusively for Medicare-covered medical expenses associated with the injury.

Think of an MSA as a financial reserve specifically designated for medical costs, helping claimants maintain Medicare eligibility while ensuring compliance with the Medicare Secondary Payer (MSP) Act.

Why are MSAs Necessary?

Compliance with the Medicare Secondary Payer (MSP) Act

The MSP Act prevents Medicare from paying for medical expenses when another entity (such as a workers’ compensation insurer) is responsible. If an injured worker is eligible for Medicare (or expected to be soon), an MSA helps ensure that Medicare is not burdened with costs that should be covered by the settlement.

Protecting the Injured Worker’s Medicare Benefits

If a settlement does not properly account for future medical costs, Medicare could deny payments for treatment related to the injury. This could leave the injured worker responsible for medical expenses that should have been accounted for in the settlement.

Avoiding Legal and Financial Risks

Failure to properly allocate funds for future medical expenses can lead to compliance issues with the Centers for Medicare & Medicaid Services (CMS). In some cases, CMS may pursue recovery from both the claimant and the insurer, leading to unnecessary legal and financial complications.

How Does an MSA Work?

Case Evaluation
- A review is conducted to determine if an MSA is necessary, typically for claimants who are Medicare-eligible or expected to become eligible within 30 months.
- Medical history and projected future treatment costs are assessed.
MSA Allocation Report
- A professional allocation report is developed to estimate the future medical costs that Medicare would typically cover over someone’s lifetime.
CMS Submission (Optional but Recommended)
- If certain review thresholds are met, the MSA proposal can be submitted to CMS for approval to ensure compliance. While not always required, CMS approval provides protection against future disputes.
Funding and Administration
- The MSA can be funded as a lump sum or through structured payments.
- The funds must be used exclusively for medical expenses related to the work injury.
- The MSA account can be self-administered by the claimant or managed by a professional administrator to ensure proper usage and record-keeping.
Exhaustion and Medicare Coverage
- Once the MSA funds are properly spent and exhausted, Medicare assumes responsibility for injury-related medical expenses.

Who Needs an MSA?

Not every workers’ compensation claim requires an MSA. However, they are generally recommended when:

The claimant is Medicare-eligible (65+ or receiving SSDI) or expected to be Medicare eligible in the next 30 months.
The settlement includes funds for future medical treatment related to the work injury.
The claim involves significant ongoing medical expenses that would typically be covered by Medicare.

If these conditions apply, it is crucial to evaluate whether an MSA is needed to avoid compliance risks and ensure the claimant’s continued access to care.

Final Thoughts

A Medicare Set-Aside is an essential tool for protecting Medicare’s interests, ensuring compliance with federal regulations, and securing long-term medical coverage for injured workers. By understanding what an MSA is and why it matters, all parties involved in a workers’ compensation claim—insurers, employers, attorneys, and injured workers—can make informed decisions that align with best practices and regulatory requirements.

If you’re navigating a workers’ compensation settlement and unsure whether an MSA is necessary, Tower MSA Partners is here to help. Our team specializes in developing compliant and cost-effective MSAs, ensuring that your settlement is both strategic and Medicare-compliant.

Stay tuned for our next blog in this series: “How Does an MSA Work?” where we’ll dive deeper into the MSA components.

Want to discuss your MSA needs? Contact Tower MSA Partners today.

CMS 2024 WCMSA Metrics: Key Trends in Medication and Treatment Costs

December 4, 2024

stethoscope and pill bottle on representing WCMSA trends

CMS 2024 WCMSA Metrics: Key Insights into Costs and Trends

The Centers for Medicare and Medicaid Services (CMS) has released its 2024 data on Workers’ Compensation Medicare Set-Aside (WCMSA) reviews. This year’s metrics highlight two significant trends: declining prescription drug costs and rising medical treatment costs.

For employers, insurers, and other stakeholders, understanding these trends is crucial for effective planning and cost management. Here’s a breakdown of the key findings and how Tower MSA stands out in the industry.

CMS WCMSA Metrics Overview: 2020–2024

CMS’s fiscal year 2024 data provides a five-year perspective on MSA reviews, comparing proposed amounts to CMS-recommended (approved) amounts. Here are the major takeaways:

Consistency in Review Numbers:
CMS completed 14,862 MSA recommendations in 2024, closely aligning with the five-year average of 15,138.
Decrease in Recommendations:
After a 9% rise in recommended amounts between 2022 and 2023, 2024 saw a 6% drop.
Stable Average MSA Amounts:
The average approved MSA decreased slightly to $85,927 in 2024 from $86,453 in 2023. However, this remains above the five-year average of $83,851.
Variance Between Proposed and Approved Amounts:
The variance, which increased to 22% in 2023, remained steady at 21% in 2024.

Key Trends in Costs

Prescription Drug Costs Continue to Decline

CMS data reveals a notable 33% decrease in average prescription drug costs over five years, from $26,574 in 2020 to $17,807 in 2024. This decline reflects:

Reduced opioid use in workers’ compensation cases.
Increased allocation of generic medications over brand-name drugs.

Treatment Costs Are Rising

While prescription costs have fallen, the average treatment costs have increased by 15% since 2020, signaling a shift in the cost structure for MSAs.

How Tower MSA Partners Compares to Industry Averages

Tower MSA Partners has consistently achieved lower costs for its clients, significantly outperforming industry averages in both total MSA and prescription drug components.

Average Approved MSA (2020-2023):
- CMS: $82,332
- Tower: $63,005 (23% lower)
Prescription Drug Component (2020-2023):
- CMS: $22,048
- Tower: $14,286 (35% lower)

Through targeted interventions like our Physician Follow-up service, Tower mitigates costs while ensuring compliance with CMS requirements.

Why CMS Metrics Matter

These annual metrics provide invaluable insights for stakeholders managing workers’ compensation cases. They not only reflect trends in CMS review processes but also offer benchmarks to evaluate cost-saving strategies.

Tower MSA’s cost-effective approach demonstrates that significant savings are possible with a robust review and allocation methodology.

Have Questions? Let’s Connect

If you want to learn more about how CMS metrics impact your workers’ compensation program—or explore cost-saving opportunities—contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or call 888.331.4941.