MEDICARE SET ASIDES

What is a Medicare Set Aside?

An MSA is a fund created in the settlement of an insurance claim.  It is established from the portion of the settlement amount that is to be used to pay for future medical expenses related to an injury/illness that would otherwise be payable by Medicare.  Funds must be established in interest-bearing accounts and may be managed by the claimant or a custodial account.

How to Determine Need for an MSA?

1)  Workers Compensation Claim
2)  Individual is a Medicare recipient at the time of Settlement
3)  Settlement is over $250,000.00.
4) There is a reasonable expectation that the claimant will become a Medicare recipient within 30 months of the settlement.  Definition of reasonable expectation:
      a) The claimant is receiving SSDI
      b) The claimant has applied for SSDI
      c) The claimant has applied for SSDI and was denied; but has the intention to appeal the denial.
5)  End Stage of Renal Disease.

The MSA Process:

1)  Determine the need for an MSA.
2)  Once the need for an MSA is determined, contact the Coordinator of Benefit Contractor (COBC) office and the Lead Contractor to notify them that an MSA is being done and that the file is being settled.  In doing so, we will know:
       a) Any conditional payments that need to be paid to Medicare by the carrier before settlement.
       b) Any discrepancies in claim payout summary.
       c) Any duplicate payment or other misunderstanding.
3) The MSA Allocator will complete the MSA with all necessary supporting documents and submit it to the COBC (Coordination of Benefits Contractor), which will then submit it to CMS (Center for Medicaid and Medicare Services) for final approval.

The MSA Components:  Three Major Parts

1)  Allocation of Settlement:
       a)  MSA initial deposit or Seed money.
       b) Cost Projection #1:  Future medical expenses covered by Medicare with annuity payout or lump sum payout to the claimant for the remaining life.
       c) Cost Projection #2:  Future medical expenses not covered by Medicare with annuity payout or lump sum payout to claimant.
       d)  Attorney’s fee.

2)  Administration of MSA Settlement
       a) Self
       b) Professional

3)   MSA Funding Method
       a) Lump Sum
       b) Annuity

Possible Consequences of not using an MSA:

Center for Medicare Services (CMS) has the right under Medicare Secondary Payer (which is a Federal Legislation that is now enforced nationwide) to:

1)  Disregard the settlement. 42 U.S.C. 1395y(b)(2)(B)(i)(ii)(iii). The terms of the settlement might not be recognized.
2)  Seek reimbursement of medical expenses paid by Medicare, which the primary payer should have made.
3)  Pursue a private cause of action for double damages against the carrier for failure to provide primary payment or reimbursement. 42 U.S.C 1395y(b)(3)(A). The Office of General Counsel may bring suit for double damages against the primary payer.

MEDICAL BILL REVIEW

The Workers Rehabilitation Medical Bill Review Service offers an efficient and cost-effective solution to your medical bill review needs.  We can process your medical bills at a fee that is less that what you are currently paying while maintain or exceeding your service requirements, guaranteed.

Many bill review service companies in today’s marketplace have different methodologies of charging for this service.  We offer a flat rate per bill.  There is no more guessing on how much you will pay for your bill review service.  We do not charge our clients for their savings; these savings are passed directly to our clients.

The major advantages of our services are the power of our proprietary bill review system, operational infrastructure and electronic data interface (EDI) capability.

Features of Provider Bill Review Services:

   Bills are reviewed and adjudicated to prevailing State Fee Schedule or Reasonable & Customary rates by experienced bill review specialists.
   Bills are further reviewed and adjudicated for:
          Over Utilization
          Bundling, Up-coding
          Prevailing Billing Practices
   Reduced administrative and processing costs associated with data entry, duplicate/resubmitted billing.
   Integration capability for better utilization.
   Electronic data interface (EDI) to transmit claims and bill review data to and from the customer, provider and claims administration.
   Four (4) working days turnaround.
   Average savings of 40-45%.
   Monthly utilization and activity reports.
   Greater flexibility and accuracy.
   Customized to meet client’s needs.
   Access to Nationwide PPO networks we have contracted with to provide medical services, hospital, pharmacy and supplies.
   Lower processing fees.
   Quality assurance program.

Bill Review Services: 

Workers Rehabilitation will provide bill review services in a commercially reasonable manner that meets statutory, industry and production of standards reporting to Client’s, including, but not limited to, providing the following services in a manner reasonably acceptable to the Client.

(a)   Workers Rehabilitation will adjudicate claims for all charges for services that are submitted on HCFA 1500, UB-92 or any other Division of Workers’ Compensation approved form.
(b)   Workers Rehabilitation will produce Explanation of Benefits (EOB) for each bill process.  Workers Rehabilitation will transmit the EOB electronically to the Client.
(c)   Workers Rehabilitation will provide the Client with a payment file in a mutually agreed format and time frame.
(d)   Workers Rehabilitation will process bills within four (4) working days of receipt of a complete and authorized claim.
(e)   Workers Rehabilitation will produce monthly reports showing the medical activity and savings achieved.

Q/A Process: 

Workers Rehabilitation is dedicated to providing quality bill review services that are responsive to our customers.  Objectives and Strategies are:

(a)  To maintain a comprehensive Quality Assurance Program, this appropriately integrates its activities with other programs and procedures.
(b)  To evaluate the goals, objectives and work plans of the program for effectiveness.  These goals, objectives and work plans are updated at least annually or more often if necessary.
(c)  To maintain high quality standards of our bill revi8ew specialists.
(e)  To check for accuracy of data entry.
(f)   To conduct daily and weekly audits.
(g)  To check for re-pricing accuracy.
(h) To incorporate a grievance process where complaints from injured employees and/or providers are promptly addressed.
(i)   To monitor for customer satisfaction.

Quality Control: 

On a daily basis, the following items are checked for accuracy on each EOB during the batching process:
   Provider Name & Address
   Provider Tax ID Number
   Provider’s Patient Account Number
   Physician’s License Number (If Applicable)
   Patient Name
   Patient Social Security Number
   Date of Loss/Injury
   Authorization Number (If Applicable)
   ICD.9 Diagnosis Codes
   Dates of Service
   CPT/REV Codes
   Unit Quality