SAN JOSE, Calif.–(BUSINESS WIRE)–EK Health Services announced today that it is offering Medicare Set-Aside (MSA) compliance services as part of its range of workers’ compensation managed care solutions for payers.
MSA compliance is a natural extension of the overall claims management process for workers’ compensation injuries, said Eunhee Kim, president and CEO of EK Health. “Like Utilization Review and Bill Review, MSA has its own distinctive process for putting the claim in the best possible position to be managed for cost effectiveness, a practice in which we excel.”
By law, carriers and other parties in workers’ compensation cases have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving workers’ compensation cases that include future medical expenses.
The set-aside amount is determined on a case-by-case basis. If a claim is not effectively managed, the set-aside amount can make settlement unfeasible.
Carriers, self-insured employers and Third Party Administrators (TPA) are especially at risk now that Medicare is establishing a database of individuals in a payer’s claims population who are receiving Medicare benefits. The responsibility is therefore with the payer to effectively manage their Medicare compliance issues, and to ensure they are not over-funding set-asides needlessly.
Additionally, since 2009, allocations for prescription medications included in an MSA must be calculated using the Average Wholesale Price (AWP). The AWP cost is significantly higher than most carriers pay contractually though a Pharmacy Benefits Manager (PBM) or Medicare, resulting in a higher per unit cost. The consequence, without proper case management, can have a huge financial impact when projecting costs over the duration of a claimant’s life expectancy.