Medicare Set-Aside
CMS recommends that parties to a Worker’s Compensation settlement set aside funds for all future medical services related to the Worker’s Compensation injury or illness that would otherwise be reimbursable by Medicare.
A Medicare Set-Aside Arrangement protects Medicare’s interests when settling future medical benefits for qualified individuals and prevents the shift of burden from the primary payer to Medicare. Section 1862(b)(2) of the Social Security Act of 42 USC 1395y(b)(2) precludes Medicare from paying a beneficiary’s medical expenses when payment has been made or can be reasonably expected to be made under a Worker’s Compensation plan.
According to the July 23, 2001 memorandum by CMS, approval of the settlement and MSA amount from the CMS Regional Office is required if (1) the claimant is a Medicare beneficiary and the settlement amount is greater than $25,000; OR (2) the claimant is not a Medicare beneficiary, but has a reasonable expectation of Medicare enrollment within 30 months AND the anticipated total settlement amount is greater than $250,000 (un-commuted).
Conditional payments are Medicare payments for which another payer is responsible. Conditional payments are made when:
- a claim is denied by the carrier
- the provider bills Medicare by mistake
- there is a long delay between the occurrence of injury and the court decision
- the carrier does not pay promptly
- because the intermediary or carrier did not know that the other coverage existed.
Medicare has a priority right of recovery of conditional payments over any other entity to the proceeds of any settlement pursuant to 42 C.F.R. § 411.47.
NOVARE MEDICARE SET-ASIDE SERVICE COMMITMENT:
- MSCC Professional Nurses complete MSA process to include on-going communication with client to move file to settlement
- PharmD reviews and prices all prescriptions using generics
- Reports meet CMS requirements resulting in high CMS Submission rate
- 10 day turnaround time
- All MSA's are one flat rate with NO HIDDEN FEES
- NO CHARGE FOR RUSH CASES!
MEDICARE SET ASIDE SERVICES:
- Review of Medical Records
- Review of Payout History
- Report preparation
- Breakdown of Medicare and non-Medicare costs
- Based on CMS guidelines
MSA SUBMISSIONS SERVICES:
- Send appropriate forms to claimant attorney, defense attorney and CMS, including SSA-3288, Medicare release of information form, and general release forms to verify Medicare eligibility and lien status.
- Obtain and organize all information as per CMS guidelines
- Transfer of files to CD-ROM format
- Monitor and follow-up with the lead contractor on submission status until the file is approved by CMS.
CONDITIONAL PAYMENT LIEN RESOLUTION SERVICES:
- Obtain information on conditional payments made from CMS
- Audit for accuracy and send corrected list of claims to CMS
- Obtain final payment demand from CMS
LINKS
CMS MEMOS
- April 3, 2009
- August 25, 2008
- May 20, 2008
- July 24, 2006
- April 25, 2006
- December 30, 2005
- July 11, 2005
- October 15, 2004
- May 7, 2004
- May 23, 2003
- April 22, 2003
- July 23, 2001
|
