MSPS

Medicare Secondary Payer Services

Novare offers a full line of compliance driven solutions accompanied with personalized service from receipt to resolution.  Our experts perform a claim specific analysist and provide recommendations for cost saving solutions while ensuring that Medicare’s interest are taken into account.

All parties in a workers’ compensation case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving cases that include future medical expenses.  The recommended method to protect Medicare’s interests is a WCMSA.  

Pursuant to 42 U.S.C. §1395y(b)(2) and § 1862(b)(2)(A)(ii), Medicare is precluded from paying for a beneficiary’s medical expenses when payment “has been made or can reasonably be expected to be made under a workers’ compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.”

Novare’s MSP services, taking Medicare’s interest into account:

  • Medicare Set Aside (MSA) Workers’ Comp and Liability
  • MSA Update
  • MSA Submission
  • Medical Cost Projection
  • MCP Update
  • MCP to MSA conversion
  • Life Care Plan
  • Conditional Payment Identification
  • Conditional Payment Dispute/Resolution
  • Final Document Submission
  • Medicaid Services
  • Medicaid Dispute/Negotiation
  • Medicare Check
  • Social Security Disability Verification
  • Rated Age Evaluation

All allocations are prepared by Registered Nurses, Certified Life Care planners and or Certified Medicare Set-Aside Consultants with over 25 years in field experience.

Centers for Medicare and Medicaid Services (CMS) guidelines and process continuously change, our MSP team keeps in constant review of CMS trends and alerts ensuring you the most up to date information.

We pride ourselves on delivering excellence with an expedited turnaround.

Description Select Option

Medicare Set Aside (MSA) Workers’ Comp and Liability

Novare MSAs are a Medicare compliant allocation that projects injury-related Medicare covered medical treatment, services and prescription needs over the claimant’s life expectancy. All MSA’s are prepared by a registered nurse, Certified Medicare Set Aside Consultants and or Certified Life Care Planners. Our allocations additionally address and identify areas of cost saving opportunity while providing a professionally tailored allocation for future injury related medical care and future pharmaceutical needs. Our Allocators bring over 25 years in field related expertise and perform an comprehensive review of medical, payment, pharmacy and claim records.  MSAs are turnaround within 10 business days and Rush return is available upon request.

Records required for MSA preparation:

  • First Report of injury
  • 2 years medical records
  • All surgical, procedure, Cat Scan and MRI reports (life of claim)
  • 2 years pharmacy history
  • 2 year all-inclusive payment history (separated by medical, identity and expense)
  • Claimant signed consent to release (if MSA is to be submitted to CMS for review/approval)

MSA Update

Novare will provide updates and or revisions on all Novare MSAs when requested.

MSA Submission

Novare will formally submit the MSA and all required documentation to CMS for approval. Our team provides CMS all required documentation and supplemental information for review. Novare prepares all MSA allocations is anticipation of CMS submission, unless otherwise instructed by the client. Our mission is to submit a cost accurate allocation producing a CMS approval of “as submitted”.  Understanding the importance of balancing claim cost with Medicare Compliance we commit ourselves to successful results. Our team monitors and anticipates CMS trends so that we may deliver efficient turnaround time and high approval rates.  Approval of an MSA is not effective until CMS receives a copy of the final executed settlement documents. Final Settlement Submission is included in our submission service.

CMS required records and documentation:

  • Claimant signed consent to release.
  • 2 years current medical record
  • All surgical, procedure, Cat Scan and MRI reports (life of claim)
  • 2 years current pharmacy history
  • 2 years current all-inclusive payment history (separated by medical, identity and expense)

Medical Cost Projection

Novare Medical Cost Projections are produced by registered nurses, Certified Medicare Set Aside Consultants and or Certified Life Care Planners. Our MCPs are prepared through a comprehensive analysis, personal to the claimant’s medical needs and are case specific. Our allocations additionally address and identify areas of cost saving opportunity while providing a professionally tailored allocation for future injury related medical care and future pharmaceutical needs. Our MCP’s are designed to provide an accurate tool for setting medical reserves and claim medication.

Required records and documentation:

  • 2 years Current medical records
  • 2 years Current pharmacy history
  • Claim payment history

MCP Update

Novare will provide updates and or revisions on all Novare MSAs when requested.

Required records and documentation:

  • Current treatment records
  • Current pharmacy records
  • Current 2 year all-inclusive payment history

MCP to MSA conversion

Novare will convert any Novare MCPs to an MSA upon request.

Required records and documentation:

  • First Report of injury
  • 2 years medical records
  • All surgical, procedure, Cat Scan and MRI reports (life of claim)
  • 2 years pharmacy history
  • 2 year all-inclusive payment history (separated by medical, identity and expense)
  • Claimant signed consent to release (if MSA is to be submitted to CMS for review/approval)

Life Care Plans

Novare Life Care Plans identify future treatment cost for all services that will likely be needed over the individual’s lifetime. These reports are highly detailed and are specific to the individual and compensable treatment needs. Onsite assessment is required unless denied by opposing council. Each member of the treatment team is contacted to identify future needs. A Life Care Plan is typically used to settle high exposure claims. Novare Life Care Plans Allocations are defensible in court and are prepared by a Registered Nurse, Certified Life Care planner, Certified Case Manager, and Certified Medicare Set Aside Consultant with over 35 years in health-related fields.

Required records and documentation:

  • All medical records life of claim
  • Claim payment history
  • Pharmacy history

Conditional Payment Identification

A potential for conditional payments arise when an injured worker is a Medicare Beneficiary. Any injury related payments that are made by Medicare are made in expectation of reimbursement. Novare’s MSP professionals will make contact with the BCRC/CRC to initiate this process. Once a CMS case identification is assigned Novare will take the appropriate actions, request a Conditional payment Letter (itemized summary of CMS charges for reimbursement), updated Conditional Payment amounts and review of charges for dispute recommendations. A conditional payment will continue to fluctuate as providers submit and Medicare payments are made. Our dedicated Conditional payment team will monitor and make recommendations throughout this process to resolution.

Required records and documentation:

  • Claimant signed proof of representation
  • Carrier signed letter of authorization (Placed on Carrier Letterhead)
  • Claimant current address, Date of Birth and Date of injury
  • Compensable Body Part (s)
  • Injury Description
  • Carrier name and contact information (address, phone and fax)
  • Attorney Information (if available)

Conditional Payment Dispute/Resolution

Our Conditional Payment team will make a comprehensive review of CMS itemized medical payment made by Medicare in expectation of reimbursement .  A formal dispute of these unrelated charges will be submitted to the BCRC/CRC for determination of removal. Our disputes identify non-compensable charges for removal and are accompanied by supporting documentation.

Required records and documentation:

  • Claimant signed proof of representation
  • Carrier signed letter of authorization (Placed on Carrier Letterhead)

Final Document Submission

Upon request final documents will be formally submitted to the appropriate Medicare Contractor.

Medicaid Services:
Our MSP professionals offer complete resolution services; Medicaid identification, disputes, negotiations and resolution.

Required records and documentation:

Medicaid requirements vary from state to state.

  • Signed HIPPA release
  • Signed proof of representation
  • Letter of Authority
  • Medical records, judgments or awards.

Medicare Check:
A verification of Medicare Beneficiary status and eligibility dates.

Required information:

  • Claimant name
  • Current Address
  • Date of Birth
  • SSN
  • Responsible reporting entity number (RRE#)

Social Security Disability Verification:
A verification of Medicare and or Social Security Disability status.

Required Release:

  • Signed SSA-3288

Rated Age Evaluation:
A comprehensive review of medical records will be completed. A submission of the findings of this review along with medical record documentation will be submitted for a rated age evaluation. This evaluation will provide an appropriate life expectancy for allocation.

Required records and documentation:

  • Claimant medical records for review