By Marty Cassavoy, Vice President of MSP Compliance, ExamWorks Clinical Solutions
The Workers’ Compensation Medicare Set-Aside (MSA) program has been a thorn in the side of claims payers for the last fifteen years. MSAs evolved from a compliance vehicle that few understood to what is now a necessary evil in resolving workers’ compensation claims involving Medicare beneficiaries (as well as those soon-to-be on Medicare). Along the way, Medicare’s review program often impeded settlement by demanding that parties increase the amount of an MSA to “adequately” protect Medicare’s interest. What’s more, parties were usually stuck with Medicare’s amount, often making settlement nearly impossible, and leading to likely overfunding of any such settlement that did occur.
A New Way Forward
In July Medicare unveiled Amended Review, a program to provide a second bite at the MSA apple. Rather than simply accept Medicare’s initial determination with respect to funding, parties are able to go back a second time with a new proposed amount – one that will hopefully allow a settlement to proceed as intended. Here are the key requirements:
- Medicare must have provided an MSA “approval” letter between one and four years prior to the date of the Amended Review request.
- The case cannot have settled by the date of the request.
- Projected future Medicare-covered care must have changed by $10,000 or 10% of the total prior approved MSA amount, whichever is greater. This is a simple calculation: if the MSA was approved at $100,000 or less, the new MSA needs to have at least a $10,000 change; if the MSA was approved at more than $100,000, the new proposed amount must differ by at least 10% than that of the original MSA.
- An Amended Review request will be rejected if the sole reason for the request is due to prescription medication price changes.
- Finally, you get one chance to obtain Amended Review. Failure to provide required information will lead to a rejected Amended Review request (i.e., there is no “development” stage like one sees with original submissions).
The Opportunity at Hand
Most workers’ compensation claims payers have some cases where prior rejection of an MSA proposal stalled a settlement. While there were always creative resolution approaches for those claims, many judges, parties, and counsel shied away from settling outside the terms of a Medicare approval letter. Amended Review presents a great opportunity to inject new life into these stale and/or stalled cases.
Practical Tips for the New Program
- Amended Review is available for cases with determinations in a rolling three year window. To target these cases for resolution, look at cases approved by Medicare just shy of four years ago.
- If the case has not settled, and it is within the one to four year window, look at the difference between the updated MSA and the CMS-approved MSA. If that figure is significant (usually $10,000 or more), consider Amended Review.
- Even if the case was approved by CMS, if it is still open it is worth consideration for Amended Review. MSAs involving large sums of money or complex treatment are worth another shot.
- Keep in mind the window of available cases changes every day, so review your stale MSA caseload for these options at least quarterly.
While Medicare has never introduced a formal appeals program for MSAs, this second chance at an MSA is a close approximation. It is a huge opportunity to put some of these cases to bed, and it allows claims payers to specifically target a subset of claims that had been written off for settlement. ExamWorks Clinical Solutions has already had tremendous success with CMS approving Amended Review requests, and it is not unusual to save hundreds of thousands of dollars on a single case. Our team of experienced attorneys, clinicians, pharmacists and life-care planners are able to assess quickly and exactingly whether Amended Review makes sense, and develop a resolution plan tailored to your needs.
About Marty Cassavoy
Marty Cassavoy is the Vice President of MSP Compliance for ExamWorks Clinical Solutions (ECS). Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer (MSP) compliance and across all insurance types.
Marty is a frequent speaker, commentator and writer on all aspects of MSP compliance, where he is often unafraid to challenge the conventional approach to Medicare problems. Marty is a member of the ECS Leadership Team, providing strategic guidance for the organization’s MSP compliance products and services. In his day-to-day role, Marty leads ECS’s Compliance Team where he and his talented team collaborate to solve problems, react to industry changes and build innovative MSP compliance solutions.
Marty can think of no greater joy than helping insurance professionals conquer their fear of MSP compliance. His goal is to simplify MSP compliance and improve problem solving skills rather than simply present a laundry list of problems. With this aim in mind, Marty and his team develop engaging and informative MSP compliance educational programs for ECS’s clients.
Prior to joining ECS, Marty was Vice President of Policy at ISO Claims Partners, where he worked for more than a decade. Marty is a graduate of Boston University and Suffolk University Law School in Boston, where he graduated with honors. Marty is a lawyer licensed to practice in the Commonwealth of Massachusetts. Outside of the MSP compliance world, Marty can often be found at a baseball diamond, soccer field, basketball court or hockey rink where he is either watching or coaching one of his three talented children.
About ExamWorks Clinical Solutions
ExamWorks Clinical Solutions is the industry leader in Medicare Secondary Payer compliance, combining Medicare Set-Aside, conditional payment, and post-settlement services. The company provides comprehensive clinical mitigation programs and medical and vocational case management to insurers, self-insureds, and third-party administrators. ExamWorks Clinical Solutions, an ExamWorks Company, is headquartered in Lawrenceville, Georgia. Learn more at: www.examworks-cs.com.