As the name suggests, an MSA is a finite sum that is set aside by the primary payer, typically in a claim settlement, based on an estimate of future health care costs for a Medicare beneficiary due to a work-related or general liability injury, illness or disease. Medicare has recommended Workers’ Compensation MSAs as a reasonable means of protecting Medicare’s interests for future medical expenses involving a Workers’ Comp claim for a Medicare beneficiary when a primary payer exists.
For example, a Medicare beneficiary who suffers a broken knee cap resulting from a fall may have been covered for the emergency room health care bills by his/her private insurance carrier, but funds may also be required for the cost of an expected knee replacement surgery sometime in the future based on a medical prognosis. These funds are referred to as a Medicare Set-Aside (MSA). MSAs can be very costly, as individuals 65 and older often require significantly more time to heal than do similar injuries incurred by younger individuals.
The goal of most MSAs today is to ensure funds are available to pay for projected future medical expenses required by a Medicare beneficiary as a result of a prior work-related injury. The recommended use of MSAs for Workers’ Compensation claims evolved from the 1980 Medicare Secondary Payer (MSP) Act, which established Medicare as a secondary payer when a primary payer exists. This was done to transfer some of the increasing financial burden from the explosive growth in federally funded health care expenditures to the private sector, such as self-insured employers, Workers’ Compensation insurance companies and liability insurance carriers.
Flagship provides innovative solutions to protect the interests of Medicare while concurrently protecting the financial resources of our clients. Sometimes that can be done without the cost of developing a formal MSA, or taking the risk of a “counter higher” (Medicare counters the proposed MSA with higher projected costs). Flagship’s dedicated legal, medical, and claims professionals provide comprehensive assessments to limit potential expenditures and compliance risks.
To create an MSA, Flagship needs the following basic information:
MSA funds must be placed in an interest bearing account. Here are the guidelines:
When the MSA fund has been depleted, a final audit is performed to assess the appropriate disbursement of the funds to determine if the beneficiary is entitled to continuing Medicare benefits. If any medical expenditures are deemed to be outside of Medicare’s coverage for the subject injury, illness or disease, future claim-related medical care through Medicare may be denied.
An MSA account can be administered by:
When the injured party has a designated representative, payee, appointed guardian/conservator or has been ruled incompetent by a court, the settling parties are required to provide this information in the MSA proposal.
Workers’ Compensation claims, and certain liability claims (on a discretionary basis) that involve personal injury. In some instances it is prudent to submit an MSA to Medicare for review and approval.
Combining years of experience in the Medicare market with consistent monitoring of Medicare’s ongoing changes, we specialize in implementing processes and procedures to keep you compliant.
As a privately held company, Flagship’s priority is to offer a consultative and flexible approach in creating a unique customized program for each of our clients. We provide several innovative solutions, depending on your needs. Our goal is to form a partnership to ensure compliance while providing the highest level of customer service.
Proper formatting for CMS review when requested by client.
Comprehensive analysis by experienced and credentialed medical, legal and claims professionals.
Intensive legal review of claims to identify potential claim resolution issues or opportunities.
Accurate future medical cost projections based on state fee schedules and CMS pricing guidelines.
Rated Age services through “A” rated (or better) insurance carriers.
Ten business days turn-around from receipt of complete medical records.
Flagship Medicare experts available to answer questions and discuss options.
Submittal process to Medicare.