Tag: MSA

MSA Amended Reviews – Key to Settlements of Old Dog Legacy Claims

October 26, 2023

Tower MSA Partners covering CMS expanded Amended Review availability for Medicare Set-Aside arrangements.

Tower MSA Partners’ Chief Compliance Officer Dan Anders’ enthusiasm for Amended Reviews kept the audience engaged during our recent Premier Webinar: Amended Review MSA Provides Second Bite at the Apple.

Several criteria dictate whether payers can submit an Amended Review, including the fact CMS needed to have approved the first MSA more than 12 months earlier. In addition, there must be a $10,000 or 10% (whichever is higher) difference between the first MSA allocation and the Amended Review MSA.

Our earlier post discussed CMS’s decision to remove the lookback period for Amended Reviews. Previously, we could only use this process if the original MSA had been approved during the last six years.  The removal of the lookback period opened the door for insurers and employers to examine their unsettled legacy claims that had any approved MSA and try to settle the claims.

Dan cautioned attendees not to submit an Amended Review MSA unless the injured worker seemed open to settlement.  “CMS’s change gave payers a second bite at the apple,” Dan said, “But it’s just one more bite, only one opportunity to obtain a new MSA.  You don’t get to eat the whole apple.”

The webinar shared facts and advice about Amended Reviews and highlighted several real case studies, including one where the second MSA amount was much higher than the first.  Some takeaways:

  • Request an MSA report to decide if an Amended Review MSA submission makes sense.
  • An Amended Review is not available until 12 months after CMS approved the first MSAA.
  • There’s no requirement to submit an Amended Review MSA for settlement purposes even if the CMS-approved MSA does not reflect current or future course of care.
  • Make sure all parties are at a stage where settlement is feasible.
  • Obtain medical documentation to support all medical and medication changes from the original MSA.
  • Unlike a regular MSA submission, where CMS requests more information and we can supplement and support the proposal in our response, the Amended Review MSA process offers no opportunity to provide documentation after submission. CMS will review what is provided and make its determination.

Attendees asked great questions:

  • Must the vendor who submitted the original MSA also submit the Amended Review MSA?

No. Tower can handle the Amended Review MSA even if a different vendor handled the original submission.

  • If an MSA was previously submitted for a Re-review, can it be submitted for an Amended Review MSA?

Yes.

  • Does the undertaking of an Amended Review make the previously submitted MSA null and void?

Only if the Amended Review MSA is submitted and approved.  The beauty of CMS-approved MSAs is that they never die.  If you can get the injured person and their attorney to agree, you can use it to settle, regardless of how outdated it is.

Like just about everything else CMS touches, the Amended Review process is complicated, and you can easily blow your one and only chance. Do not try this at home.

Dan is always happy to discuss cases and explore Amended Review and other options with you. Don’t hesitate to email him at Daniel.Anders@TowerMSA.com.

Remember, Tower can create MSA reports to help you decide if you want to pursue an Amended Review MSA. In addition, we’ll review your open claims with high CMS-approved MSAs and select those that could settle with an Amended Review MSA. We can also provide clinical recommendations to determine whether a physician statement, additional medical records or other intervention can result in a lower MSA.

Tower MSA Partners.  Don’t Settle with Anyone Else.

Premier Webinar: Amended Review MSA Provides Second Bite at the Apple

CMS now allows any previously approved MSA to have a one-time Amended Review.  This means that CMS will consider a new MSA submission that may be lower or higher than the previously approved MSA. Essentially, it is a second bite at the apple for old MSAs that, for whatever reason–they were too high, or the injured worker was not ready to settle–weren’t utilized for settlement.

Tower is pleased to feature our Chief Compliance Officer, Dan Anders, who on Wednesday, October 4, at 2:00 PM ET, will address the following topics:

  • Criteria for an Amended Review MSA
  • Is an Amended Review MSA required?
  • Documentation to support an Amended Review MSA
  • Examples of Amended Review MSA submissions

Besides Amended Review MSAs, the webinar will also consider how MSA Re-Reviews can reduce MSA amount resulting from CMS counter-highers.

A Q&A session will follow the presentation, and you can provide questions when you register. Please click the link below and register today!

Please note there is no CEU credit offered for this webinar.

Register Here

Easy MSA Cost Savings Through Structured Settlements

June 21, 2023

Easy MSA Cost Savings Through Structured Settlements.

Tower’s structured settlement partner, Arcadia Settlements Group, gave an in-depth overview of how Medicare Set-Asides, structured settlements, and professional administration facilitate workers’ comp settlements during our recent Premiere Webinar. Tower MSA Partners Chief Compliance Officer, Dan Anders, moderated the informative session that featured Alisa Hofmann, Arcadia’s VP of Workers’ Comp and Medicare Practices, and Lori Vaughn, who oversees its structured settlement programs.

As you may know, workers’ comp settlements can be paid out in a lump sum or through structured settlements.  Here are some not-so-fun facts about lump sums:

  • 25-30% of injured people exhaust lump sum settlement funds within 2-3 months.
  • 85-90% of injured people dissipate lump sum settlement funds within 2-5 years.

When injured workers exhaust these funds, if they are Medicare beneficiaries, they turn to Medicare to cover injury-related medical bills. And the whole point of the Medicare Secondary Payer Act is to prevent this.

Structured settlements protect the MSA funds by paying them over time as an annuity. The injured worker receives two years of the MSA allocation at settlement plus the cost of a first procedure or replacement if there are any. The rest of the MSA comes in annual payments, so the injured worker receives a consistent stream of funds for injury-related care over their lifetime.

For payers, this arrangement offers significant savings and a path to faster claim resolution, especially when paired with professional administration. And, like an MSA, the structured settlement shows Medicare that its interests are protected.

A Couple of Takeaways:

  • Structured settlements aren’t only for MSAs. They can be used for indemnity and funds for healthcare services and equipment not covered by Medicare. Even attorneys can be paid through these.
  • CMS-approved lump sum MSAs can be converted to a structured MSA but require submission to CMS of an attestation from the injured worker agreeing to the change.
  • It is easier to submit the MSA to CMS in the structured settlement format as if it is later decided to go with a lump sum there is no need to submit an injured worker letter to CMS agreeing to the change. In short, submitting in this format saves time, money and frustration.

Hofmann and Vaughn also discussed self-administration versus professional administration of the MSA. They urged payers to educate injured workers on the risks, rules, and responsibilities of MSA administration.

CMS prefers professional administration. Plus, some companies like our partner Ametros provide medical and pharmaceutical savings in addition to managing the fund and reporting.

With examples that show how structured settlements are calculated, the webinar is great for new claims representatives and those who want a refresh on settlement tools.  If you’d like to receive more information on structuring an MSA or a link to the recording, please email your request to Dan Anders at daniel.anders@towermsa.com.

 

CMS News Roundup: New Conditional Payment Appeals Guide & Webinar on Section 111 Reporting

May 25, 2023

Tower MSA Partners covers CMS new guide on Medicare conditional payment appeals and the upcoming Section 111 reporting webinar.

The Centers for Medicare and Medicaid Services (CMS) recently released a how-to guide for appealing Medicare conditional payment demands. The Non-Group Health Plan (NGHP) Applicable Plan Appeals Reference Guide consolidates conditional payment rules and best practices that the agency has issued through webinars, slides and its website.

Section 2.0 gives a breakdown of the appeals levels and explains how to submit an appeal and authorization/letter of authority requirements.  Section 3.0 details what can be appealed and supporting documentation.  Section 4.0 lists additional resources.  Finally, an appendix provides sample letters and model language for applicable plans to appoint recovery agents.

It is important to note that this guide does not cover Conditional Payment Notices (CPNs), which are issued before demand letters to allow the recipient 30 days to dispute the charges.  However, the bases for CPN disputes are the same as those found in Section 3.0.  When the dispute fails or is not timely, a demand letter is issued and the demand letter can be appealed, even with the same arguments used to dispute the CPN.

We appreciate CMS taking the time to draft and release this guide.  It joins the WCMSA Reference Guide and the Section 111 User Guide as critical reference tools for anyone impacted by Medicare Secondary Payer compliance.

CMS Section 111 Non-Group Health Plan (NGHP) Unsolicited Response File Webinar

The Centers for Medicare and Medicaid Services (CMS) recently published a Section 111 reporting webinar notice for a webinar on June 6, 2023 at 1:00 PM ET and states:

CMS will be hosting a webinar regarding the upcoming implementation of the Section 111 NGHP
Unsolicited Response File option. The format will be opening remarks by CMS, a presentation that will include background as well as how to opt in and what to expect, followed by a question and answer session. For questions regarding this topic, prior to the webinar, please utilize the Section 111 Resource Mailbox PL110- 173SEC111-comments@cms.hhs.gov

As of July 2023, Responsible Reporting Entities (RREs) can opt-in to receive a monthly “NGHP Unsolicited Response File” via the Section 111 secure website. Per CMS, the file “will provide critical information about updates to ORM records originally submitted in the last 12 months and allow RREs to either update their internal data or contact the Benefits Coordination & Recovery Center (BCRC) for a correction.”

It is important for an RRE to review and confirm that the changes made by the BCRC and listed in this report are correct.  If not, then the BCRC must be contacted to advise them that the RRE disagrees with the change made by the BCRC.  We encourage anyone involved in managing Section 111 reporting to tune in.  Please note that there is no pre-registration; the link and call-in numbers are on the notice.  You log in shortly before the webinar’s start time.

Related Articles

CMS to Provide RREs with Response File on ORM Record Changes

Premier Webinar: Easy MSA Cost Savings Through Structured Settlements

May 18, 2023

Tower MSA Partners webinar on structured settlements for Medicare Set-Asides cost savings and compliance.

One of the easiest ways to lower the settlement cost is through a structured Medicare Set-Aside. Not only does this reduce the payer’s cost of funding the MSA, but it also provides the injured worker a consistent stream of funds for injury-related medical care over their lifetime.

 On June 7 at 2 pm (EDT) Tower will present an informative session on structured settlements for MSAs. Tower’s Chief Compliance Officer will moderate a special guest panel from Arcadia: Alisa Hofmann, Vice President – Workers’ Compensation and Medicare Practices and Lori Vaughn, Director of Arcadia Client Programs. This hour-long webinar will show how structured MSAs can benefit all stakeholders in a settlement – the injured party, Medicare and the insurance carrier or employer.

Attendees will learn:

  • How to work with a structured settlement provider to incorporate an MSA structure into settlement.
  • The methodology CMS uses to calculate a structured MSA.
  • Rules around converting a CMS-approved lump sum MSA into a structured MSA.
  • The role of a structured settlement broker pre-settlement, during settlement negotiations and post-settlement.

A Q&A session will follow the presentation, and you can provide questions you’d like to have answered when you register. Please click the link below and register today!

Please note that there is no CEU credit offered for this webinar.

Register here.

About Alisa Hofmann:

Alisa is the Vice President of Workers’ Compensation and Medicare Practices at Arcadia Settlements Group and currently works on the Business Development team. She has been handling and overseeing Workers’ Compensation claims for almost three decades with various national carriers.  Alisa obtained her BA in Organizational Communication at Otterbein University. She maintains her adjuster licensing in many states, also holds Life, Health, and Accident Licensing, and many Insurance Accreditations. Alisa has been an active member of the National Structured Settlement Trade Association since 2019, and a member of The MSP Network where she serves on the Professional Administration and Structure-Education Committee.

About Lori Vaughn:

Lori Vaughn has 15+ years of experience in the structured settlement industry and currently oversees structured settlement programs for multiple workers’ compensation and private insurance carrier clients. She leads teams of consultants, case managers, and corporate employees, and is the primary point of contact for the corporate management team for each client. Lori obtained her BS in Kinesiology from California State University, Fresno, and her MS in Kinesiology from California Baptist University. She holds her Life, Health, and Accident licenses in many states and is a member of the National Structured Settlements Trade Association.

CMS Significantly Expands Amended Review MSA Availability

May 17, 2023

Tower MSA Partners covering CMS expanded Amended Review availability for Medicare Set-Aside arrangements.

The Centers for Medicare and Medicaid Services (CMS) announced the expansion of its Amended Review policy to significantly more MSAs in the latest update to its WCMSA Reference Guide, Version 3.9. The Amended Review process was previously limited to MSAs approved within the last 12 to 60 months.

The 60-month limitation is now gone, opening the door to a second bite at the apple for any MSA approved over 12 months prior.

Does Your MSA Qualify?

CMS provides the following criteria for an Amended Review:

Where the following criteria are met, CMS will permit a one-time request for re-review in the form of a submission of a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release information, and a summary of expected future care.

  • CMS has issued a conditional approval/approved amount at least 12 months prior.
  • The case has not yet been settled as of the date of the request for re-review.
  • Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

A claim that meets these criteria qualifies for an Amended Review.

Other Notable Updates

The CMS Regional Offices no longer approve the MSA before its release to the submitter.  For a brief history, when CMS introduced the MSA review process in 2001 the regional offices reviewed the MSA submissions.  CMS replaced their review responsibility in 2005 by introducing a centralized review contractor, the Workers Compensation Review Contractor (WCRC).  Since then, the regional offices approved the MSA recommendation made by the WCRC.

While no longer putting their stamp of approval on the MSA, the regional offices are still responsible for the receipt and review of final settlement documents to confirm the proper funding of the MSA.

Also, as part of the update, CMS clarified pricing methodology around intrathecal pumps, spinal cord stimulators, and peripheral nerve stimulator replacement frequency.

Practical Implications

The big news is the availability of Amended Review MSAs for any prior approval which otherwise meets the above-defined criteria.  We recommend that payers review their files to identify open medical claims which may now be eligible for an Amended Review. Tower stands ready to assist you with such a review and identify claims that can now be settled.  Please contact us for further consultation.

The Critical Care Nurses Give MSAs

May 11, 2023

Graphic of The Critical Care Nurses Give MSAs and photo of Brittney O'Neal, a nurse and Tower’s Director of Clinical Operations.

In the second installment of our quarterly series, “Tower Partners: People Behind the Settlements,” and in celebration of Nurses Week, we spotlight Brittney O’Neal, our Director of Clinical Operations. A nurse, Brittney oversees the team of nurses that produces our Medicare Set-asides (MSAs).

There are so many elements and areas of expertise needed to develop an MSA that is fair, reasonable and compliant.  Or, as we say: optimized. If Tower’s MSA operation was in the shape of a wheel, Brittney would be the hub.  Read on to learn more about her and how our MSAs are written to be effective settlement tools.

  1. What does your position as Director of Clinical Operations entail? And how does your role impact Tower’s clients?

I lead clinical operations which includes MSA writing, quality assurance and our Physician Follow-up service. We have a team of RNs who review the records and write MSA reports.  In so doing, they identify potential treatment and pharmacy problems and make intervention and mitigation strategies. As part of our quality assurance, I review MSA allocations for accuracy and make necessary corrections before they are delivered to our clients.  I also oversee our Physician Follow-up team, which is contacting treating physicians to resolve many of the problems we identified in writing the MSA.

Client communication is vitally important. I’m available to answer questions from clients and prospects and help them put together a plan of action to settle a claim.

  1. What led you to become a nurse? What experiences shaped your professional journey?

I actually started in the pharmacy field, wanting to become a pharmacist. However, one of my mentors told me that the industry was moving away from patient care and that I should look into more of the medical side.

  1. How did you get into MSP compliance and MSAs?

Honestly, by chance. I was a pharmacy technician looking for something different and was fortunate to land an interview with Tower MSA Partners. Kristine Dudley, Tower’s Chief Operating Officer, gave me an opportunity to turn a job into a career.

  1. How does being a nurse help you in your job at Tower?

Being a nurse enables you to better understand the medical material you are reading to in turn prepare an accurate allocation. It guides your approach to researching services and Medicare coverage and the ability to provide intervention strategies.

  1. What part of the job do you find the most rewarding?

I enjoy being able to help our teams and clients navigate the different aspects of this industry.  It’s great to be able to teach and share my knowledge while also learning from others. It is also rewarding to hear from clients who are grateful for the cost-saving measures our team accomplishes and the turn-around time of the reports.

  1. What are some of the things clients ask about most often?

Many questions include whether an MSA or Medical Cost Projection (MCP) is needed, CMS review thresholds, and the Amended Review process. Other questions deal with mitigation tactics to help with cost-saving measures.

  1. How do you facilitate the settlement of claims for Tower clients?

Everything Tower does is designed to facilitate claims settlement.  Carefully reviewing claims for cost drivers, like the wrong body part or duplicative or discontinued drugs. (That pharmacy background really came in handy!)  Turning around reports quickly and recommending and implementing clinical interventions to eliminate unnecessary costs.  Physician Follow-up ensures that treatment changes are properly recorded in medical records and that we have a signed physician statement so CMS can approve our MSA.

  1. Where did you attend school/degrees?

I earned an Associate of Arts degree from Palm Beach State College, then an Associate Degree in Nursing (ADN) from HCI College, also in Palm Beach, Florida.

  1. What do you like best about working for Tower?

The close-knit family atmosphere. No matter what “title” one holds, we all understand the different levels of the workflow and are willing to assist in various areas when needed. Everyone is willing to share their knowledge so that other members can better understand the MSA/CMS process, along with other MSP matters, such as conditional payments and mandatory reporting.

  1. How do you think Tower sets itself apart from companies that sell the same/similar services?

I feel Tower MSA Partners sets itself apart from other companies by promptly being available for our clients to speak with and by having attorneys on staff for consultation. Another way is our free Physician Follow-up service and fast turn-around time on reports.

  1. Where did you grow up, and where do you live now?

I was Born in Long Island, NY, and moved to Palm Beach County, FL as a child.  Now we’re living in Saint Lucie County, FL.

  1. Tell us about your background and family.

Prior to joining this industry, I worked in retail and hospital pharmacy which assisted me with transitioning into the MSA world and going on to pursue my RN. My husband is a Firefighter/Paramedic, and we have three children (12, 9, and 5).

  1. What do you like to do on your time off?

On my off-time, I am a busy wife/mom running around to football practices/games and will soon start softball for my baby girl. I also enjoy weightlifting with my husband and family outings.

Thank you to Brittney and all our Tower nurses for your commitment to providing our clients with the highest level of service.  Happy Nurses Week!

Celebrex and Abilify Price Drops Trigger MSA Reductions

December 14, 2020

Vial of pills illustrating MSA Reductions in RX costs

Recently, the lowest average wholesale price of Celebrex 200mg and the price of multiple strengths of Abilify dropped dramatically resulting in major MSA reductions.
 
A widely used, non-steroidal anti-inflammatory drug, Celebrex (Celecoxib), is FDA-approved for several conditions:

  • Ankylosing spondylitis
  • Juvenile rheumatoid arthritis
  • Acute migraines
  • Osteoarthritis
  • Acute pain
  • Primary dysmenorrhea
  • Rheumatoid arthritis

Per Red Book, the lowest average wholesale price for Celecoxib 200mg dropped from $1.79 to $0.33, an 81.56% price reduction.
 
Abilify (Aripiprazole) is an antipsychotic drug FDA-approved for the following conditions: 

  • Schizophrenia
  • Acute treatment of manic and mixed episodes associated with bipolar
  • Adjunctive treatment of major depressive disorder
  • Irritability associated with autistic disorder
  • Treatment of Tourette’s disorder

Per Red Book, the lowest average wholesale price for multiple strengths (2mg to 30mg) of Aripiprazole dropped from the $30 to $36 range to a range of $0.07 to $0.17 per dose, an almost 100% price reduction.
 
Tower Action in Response
 
Because Tower’s system tracks all medications allocated in MSA reports, we have already pulled reports from the past two years that allocated these medications and advised clients of the potential for MSA reductions. You can also contact us to determine whether a particular MSA qualifies for MSA reductions.  Revisions to the MSA can be done now or prior to MSA submission to CMS.
 
Please contact Dan Anders, Tower’s Chief Compliance Officer, at Daniel.anders@towermsa.com or (888) 331-4941 with questions.

Need a Medicare Set Aside Second Opinion?

October 27, 2020

nurse conducting research for a Medicare Set Aside Second Opinion in a manual

Has a Medicare Set Aside ever disrupted one of your settlements?  Any one of these things — unexpected medical, surgical or pharmacy costs, compliance issues, the way MSA administration will be handled, or the presence or absence of a structured settlement–can halt negotiations. 

Tower addresses cost drivers and deals with compliance situations long before preparing an MSA, so our clients don’t have to worry about MSAs impeding settlements and injured workers can be assured that their future medical needs will be met . 

However, recently we’ve been asked to review MSAs prepared by other companies and found significant cost drivers and other obstacles to settlements.  Fortunately, our free Medicare Set Aside Second Opinion service saved the settlements and helped to secure claim closures. 

Medicare Set Aside Second Opinion Case Study

Here’s one case. Based on her experience with managing a claim and its costs, an adjuster thought the $220,000 MSA produced by another MSP provider was too high and asked us to review it.

Following our standard workflow for new MSAs, our Intake Team compared the MSA’s “accepted body parts” against the client’s claim system and found significant discrepancies.

The MSA allocated for a lifetime’s supply of sertraline, a drug used to treat anxiety and depression. However, “psyche/stress” was not an accepted body part and the workers’ comp insurer had not been paying for it. 

Tower drafted a Body Part Letter that clarified the compensable conditions and specified those that were not accepted by or paid for by the insurer. Removing the drug from the allocation saved more than $58,000.

This 2nd Opinion review also detected recommendations for inappropriate medical treatment, including an unnecessary bladder surgery. Our Physician Follow Up Service – available at no extra cost to our clients – contacted the physician and obtained written confirmation of this, reducing the allocation by another $37,000+.  We also obtained a rated age from K.P. Underwriting that further reduced the treatment and prescription cost over life expectancy.  The total savings came to over $98,000.

MSA Value is in Claim Closure 

How could we do this when the other provider couldn’t?  It comes down to our philosophy and attitude.

Tower does not treat MSAs as commodities. Instead, we recognize that the real business value of an MSA is in its ability to facilitate claim settlement and closure.

Our role is to collaborate with clients to analyze and assess risk, review medical and pharmacy records to determine Medicare exposure, intervene when treatment changes are needed, and recommend the appropriate time to complete the MSA.

In short, we proactively work to reduce costs and posture files for settlement.

How We Achieve Settlement Success

We created MSA best-practices technology and continually update it to make sure we can always accurately allocate the MSA without overfunding.  Our MSP Automation Suite contains the very latest CMS coverage, coding and individual state pricing data.  We measure everything and analyze CMS responses line by line so we know what the agency will accept, what it won’t and when to push. 

We know where cost drivers tend to hide, and our Intake and Clinical Teams are trained to hunt them down. We know which interventions to apply at the right time to reduce costs.  We know how to phrase treatment and pharmacy changes and supply the precise documentation CMS needs to approve the MSA.

And we do all this the first time around, so you won’t need a second opinion. 


With Tower, payers can enter settlement negotiations with realistic MSAs that they can explain and defend.  (We’ll participate in these negotiations if you’d like.) 

Settle well the first time with Tower. But, if you have a questionable MSA, let us give you our free 2nd opinion. Download more information here or refer an MSA for a 2nd Opinion by contacting our Intake Team at 888-331-4941 or referrals@towermsa.com.

NAMSAP Bulletin Highlights Meeting with CMS on Liability MSA Reviews

August 16, 2018

man holding transparent icons of people with stakeholder in the center

Recently, the National Alliance of Medicare Set-Aside Professionals (NAMSAP) released a Special Edition Bulletin providing insight into a meeting between CMS and NAMSAP representatives on the topic of the planned expansion of the Workers’ Compensation MSA review process to liability MSA Reviews.  NAMSAP’s April 2018 meeting was one of several with stakeholder organizations.

Your writer was one of the NAMSAP representatives who had the privilege of meeting with CMS to hear and discuss how such a Liability MSA Reviews may work.   Mr. Tom Stanley, the Co-Chair of NAMSAP’s Liability Committee provided a summary of the following meeting highlights in the bulletin:

  • CMS stated they have an 18-month timeframe (from April 2018) before it rolls out a LMSA Review program.
  • The program would be voluntary.
  • CMS has indicated that their enforcement mechanism is the denial of services.
  • CMS felt strongly that the injured party must receive something (free and clear) through settlement.
  • CMS would not review an LMSA until Settlement has been reached.
  • CMS feels a LMSA is exclusively the responsibility of the plaintiff.
  • Regarding LMSA’s, CMS made it clear that the defendant(s), and their insurers, are not a target.
  • Medicare pricing of services was discussed.
  • CMS does not feel it can mandate professional administration.
  • CMS would publish a LMSA Reference Guide.
  • Eligibility remains the same as the current WCMSA system – Medicare beneficiaries or injured parties who have a reasonable expectation of Medicare eligibility within 30 months. Per statute, Medicare’s interest must be considered in every claim.
  • A workload threshold of $250,000 is anticipated – “NO SAFE HARBOR”. This level mirrors the $25,000 workload threshold for WCMSA’s.
  • For settlements between $250,000 and $750,000 threshold, CMS approval is available and encouraged by CMS. CMS would apply “a formula” to determine the LMSA amount. Starting with the total settlement amount, CMS would subtract certain expenses and apply the discount factor to total settlement.
  • Above $750,000 level is a full commutation. A traditional MSA would be prepared and, if submitted to CMS, evaluated by CMS for adequacy.

As Mr. Stanley advised, “everything discussed in the meeting was subject to change and related to liability Medicare Set-Asides only.”  I would like to emphasize that point as well.  You should not in anyway take the above points as final, rather they are points of discussion as CMS continues to listen to stakeholders and assess the best method for protecting Medicare’s interests in post-liability settlement injury-related medical.

Importantly, CMS realizes that in protecting those interests an eventual voluntary LMSA review process must continue to provide an incentive for the parties to settle their case.   Consequently, some type of apportionment to ensure the plaintiff receives a portion of the settlement monies is expected in any final review process.

NAMSAP will to continue to dialogue with CMS and also discuss with its membership, both through a webinar and at the annual conference, the points presented by CMS.  Given the launch of a CMS LMSA review process is not expected for some time, Tower MSA Partners will shortly be releasing a white paper on best practices for addressing future medicals in liability settlements.

If you have any questions or would like to discuss the topic of LMSAs further, please contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or Daniel.anders@towermsa.com.

Related:

Liability Settlement Solutions