Medicare Set-Asides

Medicare Set-Aside (MSA)
Ensuring a favorable and appropriate Medicare Set-Aside (MSA) decision is the result of careful attention to the thousands of relevant details that are generated by the underlying legal case, whether it is a Workers’ Compensation (WC) claim, a No-Fault case, or a disputed Liability claim. Without an accurate MSA determination, the injured person, their insurer, their employer, and Medicare each face the prospect of incurring future medical costs related to the injury that should have been negotiated and resolved within the underlying legal claim. An MSA gives each party to the case a resolution to their rights and obligations as those relate to the interests of the others, and gives the case appropriate and final closure.

Assurance from Start to Finish

At CompEx MSA, we evaluate and manage the MSA case through all three of its stages:

  • From the commencement of settlement discussions
  • Through Acquisition of the MSA Agreement
  • To Account Administration After Finalization of Settlement

While Avoiding Costly Mistakes

Mistakes happen, but if an error affects Medicare’s right to reimbursement or subrogation, that agency has laid out possible penalties to prevent it, and its constituents, from inappropriately paying for healthcare services that are rightly the obligations of another carrier. At the least, Medicare can deny payments for the injuries until the full amount of the legal settlement is exhausted. At the worst, the agency can refuse to pay any medical expenses for the condition, and may even seek double damages against all parties if negligence or intentional malfeasance is involved.  42 CFR Section 411.40 and 42 CFR Section 411.46

Accordingly, ensuring an appropriate and proper resolution to the underlying injury case protects each of the claimant, their insurer, their employer, and Medicare. When the MSA is properly administered, there is no danger that Medicare might deny claims for this or future healthcare costs.

CompEx MSA is your trusted and comprehensive Medicare Set-Aside and Compliance Provider.

Essential Insurer Reporting (MIR)

Florida-based CompEx MSA manages MIR documentation for employer and insurer clients across the United States. Our comprehensive MIR practice includes all reporting elements that are required by Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA – 42 U.S.C. §1395y(b)(7)).

Since 2007, when the MMSEA was enacted, the Centers for Medicare and Medicaid (CMS) have required reports about payments made to Medicare recipients by health insurers under group health plans (GHP) or by third-party insurance carriers (non-group health plans, or NGHP) for injuries caused on the job or through by the actions of another (either in a liability or a no-fault case). The provisions for these insurance payers care are found at 42 U.S.C. 1395y(b)(8).

Full Service Compliance Reporting

CompEx MSA ensures full compliance with all reporting standards and requirements of both the MMSEA and the Mandatory Secondary Payer (MSP) Act, including:

  • Accurate registration and appropriate formatting of the account on the Coordination of Benefits Secure Website (COBSW);

  • Identification of all Responsible Reporting Entities (RRE’s);

  • Identification of active and inactive covered individuals;

  • Identification of Small Employer Exceptions (SEE’s);

  • Quarterly MSP file submission updates;

  • Processing MSP response files;

  • Processing of Non-MSP requirements;

  • Facilitation of Codes, including True-Out-Of-Pocket (TrOOP), RxBIN and PCN codes;

  • RDA Retiree files submissions;

  • Testing requirements, and much more.

Using Secure and Safe Technology

CompEx MSA experts have the electronic reporting systems in place and deep comprehension of the rules and regulations to ensure safe and effective reporting, including:

  • Secure and safe digital file transfers;

  • Customizable data integration with any available claims system;

  • Analysis of queries, reporting and conditional payment concerns;

  • Audit Trails;, and

  • Easy to understand reports.

At CompEx MSA, our professionals ensure employers and insurers are in compliance with applicable Medicare laws when their employees or insureds are injured.

MSAs and Liability Cases

MSA Liability

Many insurers are perplexed about their obligation, if any, to generate a Medicare Set-Aside account for their insureds who are injured in a no-fault situation or through the negligence of another. Although CMS (the Centers for Medicare and Medicaid) requires notification of all claims made by Medicare recipients for injuries by any cause, there is, at present, no requirement that an MSA be created in a liability case.


Not Required but Strongly Recommended

However, an MSA is usually always a good idea in any injury case because it requires an in-depth risk assessment for potential future obligations related to current and present injuries. The Liability MSA (LMSA) is an excellent risk-management tool for every insuring business because it reduces the risk of unnecessary future expenses on a closed case. And, because the law requires all Insurers to keep Medicare’s interests in mind when resolving injury cases, voluntarily seeking an MSA in a liability case is direct evidence that the Insurance company is taking that obligation seriously.


Present Assurance of Future Obligations

Accordingly, whenever there are potential future health care and drug costs due to work-related or negligence-based injuries, an LMSA agreement gives all case participants assurances of two critical case factors:

  • that there will be sufficient non-Medicare funding available to cover medical expenses for those injuries after the worker’s compensation case closes, and

  • that the parties responsible for reserving those funds do so appropriately.


Tools for Negotiation


Additionally, an LMSA can also be a valuable tool for entities seeking medical care damages in a liability case because they can use it to leverage a more favorable settlement. Just as in the WC case, a Medicare-vetted statement of the probable costs of future health care and drug treatment requirements estimates for the injured party the monetary value of future care costs that are anticipated after the liability case closes. Accordingly, seeking an MSA gives CMS notice that its interests have been considered, and provides a valuable tool upon which to base a more favorable settlement.

At this time, there are no CMS regulations requiring the establishment of an MSA in a liability case (or any case). However, the Medicare Secondary Payer Act (MSP) requires that any entity that provides payments to a Medicare enrollee must notify Medicare of that fact and protect Medicare’s interests in the process. And, if LMSAs are held to the same standards as WCMSAs, then the MSP also gives Medicare the right to seek double damages when conditional payments have been disbursed to an Enrollee and not reported to Medicare, and Medicare has not been reimbursed for them.

Medical Cost Projections

Medical cost projections

Florida-based CompEx MSA has over 15 years of medical cost project experience, which gives their professionals critical insights into the processes of evaluating the future costs of care when significant injuries are sustained.


Accurate Estimates

Estimating future costs of health care services is often the most complex aspect of any injury case, whether the injury happened on the job, in a no-fault situation, or as a result of negligence. And, because every injury is unique and every injured person is different, our case management staff are trained to pay close attention to detail regarding the injury itself, the medical providers involved, the characteristics of the injured individual, and the fluctuations in costs that occur in health care markets.


Effective Strategies

By employing exhaustive investigations and utilize cutting-edge predictive analytics to clarify the Claimant’s health condition, state-specific treatment recommendations, medical services and prescription drug pricing guidelines, and other clinical inputs, CompEx MSA staff can determine the most effective strategy to establish appropriate future care reserves and optimize settlement opportunities.

Professional Administration

Most employers with injured workers are adept at managing the Workers Compensation case to a satisfactory settlement, including procuring a Medicare Set-Aside (MSA) agreement. Once the case settles, however, managing the resulting MSA account can take as much or more time for the claimant to administer as did the original case.

The MSA agreement protects the interests of both the Claimant and Medicare. For the Claimant, the agreement ensures that there is money available to cover the costs of future medical services rendered for the subject injury. For Medicare, the MSA ensures that its interests have been properly managed in the underlying case, and that it will not be making payments for services that are not rightly its responsibility. Proper administration of the account ensures that the interests of both the Claimant and Medicare are protected for the life of the agreement.

As in most government related interactions, the MSA agreement requires ongoing proof that the money is being used appropriately and only for the subject injury, and that documented proof of those facts must be submitted to CMS on a regular basis. Many claimants are unfamiliar with the processes and procedures required by Medicare when reporting MSA data, but even small glitches or gaps in documentation have the capacity to stall the account. Consequently, many claimants, and the employers who assist with set-up of the MSA account, access the services of a professional Medicare Set-Aside agent to coordinate the data and make timely and proper reports on their behalf.

Expertly Managing Every Case

Since 2000, the administrative professionals at CompEx MSA have provided the best case management option to ensure that the health of the injured worker is restored as quickly as possible, and that the interests of CMS (the Centers for Medicare and Medicaid) are protected throughout the process. By encouraging the use of a professional MSA agent, employers and insurers are also protecting their own entity from future concerns that might arise if those agreements are improperly managed, and.or if Medicare and CMS don’t receive appropriate reports on behalf of the Claimant. The Custodian ensures the file is managed according to Medicare guidelines and that neither the insurer nor the employer is at risk of violating the terms of the agreement.

At CompEx MSA, our professional administration service providers ensure that each MSA is managed comprehensively and appropriately, according to its terms and CMS rules:

  • We ensure the MSA bank account fits the criteria required by MSA rules

  • We help clarify which expenses are proper to be drawn from the account, and which are not

  • We will assist health care providers to establish appropriate billing documents that contain only approved prices and that conform to the MSA requirements

  • Whenever possible, we will seek discounts and other options that provide the best care for the best price

  • We manage the payment process so that all appropriate providers, including doctors, therapists, hospitals, and others, get paid for their services only from the MSA account,

  • We sort and record all documentation, including receipts, to ensure accuracy of reporting

  • We produce the annual reports that describe the activities of the funds throughout the year

  • We will assist with any modifications that may be required, including in the event the Medicare status changes. In the event the MSA is exhausted before the injury fully resolves, we will also help to establish the needed CMS support.

Ensuring Future Compliance, Too

Additionally, CompEx MSA also tracks MSA rules as they change over time. Recently, the agency has issued new LMSA rules that appear to suggest more rules are coming; many of our current clients will be affected by these and future regulations. Accessing CompEx MSA’s professional administrative services will keep both current and future clients in compliance with both current and future rules and regulations.

There are always questions that arise as the MSA process continues and CompEx MSA’s professional account managers are always available to assist with finding answers and resolving issues.

Drug Utilization Review (DUR)

Drug Utilization Reviews and Peer to Peer Conferences

CompEx offers Drug Utilization Reviews and Peer to Peer conferences to control the cost of medications throughout the life of the claim or when securing CMS approval of Medicare Set Asides in connection with settlements of workers’ compensation claims.

Life Care Plans

life care plan
A comprehensive Life Care Plan considers not just the circumstances of the individual, but also their family, caregivers and professional services providers. With the goal of establishing the highest quality of life possible, including both medical and non-medical needs, CompEx MSA professionals use best-practice case management skills to accurately estimate and project care costs for the lifetime of the injured person.

When the worst happens and a catastrophic injury occurs, CompEx MSA professionals will help employers or adjusters ensure their clients experience optimal outcomes, and are comfortable and well cared for, for as long as they need those services.

Data Analytics

Data Analytics
How much is too much? For over 15 years, CompEx MSA professionals have been comparing expended costs against best practices and industry averages to give our clients insights into what they should be paying on behalf of their injured employees or insureds.

Managing health care costs is a never-ending quest for accurate information. There are always ongoing changes in the health care markets as the prices of pharmaceuticals and services rise and fall because of social or political maneuvering or even simply from one supplier to another. At CompEx MSA, we use data analytic technology to track industry fluctuations so our clients always have the best numbers and can make the best decisions possible for their claimants.

Conditional Payment Services

At CompEx MSA, 15 years of experience have trained our professional account administrators to understand the complex rules surrounding the health care needs of injured Medicare and Medicaid recipients. That’s why we track every case through each of its different courses, including when Medicare or Medicaid have made payments to health care providers for services offered to a Medicare or Medicaid recipient that are the responsibility of an employer or another insurance carrier.


Medicare Conditional Payments

Pursuant to the Medicare Secondary Payer law (42 U.S.C. § 1395y(b)), when Medicare makes these conditional payments to health care providers, it has the right to be reimbursed for those expenses. Assessing, itemizing, and reporting those expenses is mandatory practice for all employers and insurers who assist injured Medicare recipients when they are injured on the job, or by a third party.

Within the underlying case, Medicare’s reimbursement interest is registered as a lien against the final resolution of the case and that value will be dispersed to CMS before any other funds are released from the settlement proceeds. Resolution of the lien means communicating about rights and obligations related to the lien with all parties of the case who have an interest in the final settlement, including CMS, the Coordination of Benefits Contractor, the Medicare Secondary Payor Contractor, and, especially, the injured party’s attorney.


Medicaid Conditional Payments

Unlike Medicare, Medicaid is, by law, the “payer of last resort,” which means that any other party legally responsible for health care costs of injured workers must pay the full complement of their obligation before Medicaid can be compelled to contribute funds to the case. Medicaid provides coverage to specified populations – the elderly, pregnant women, disabled people of any age, the blind, and children with no other health care coverage. Each category of Medicaid applicants has a different set of qualifying requirements that must be satisfied to receive Medicaid benefits. Sometimes injured workers (or those injured through the negligence of another) are ‘dual eligible’ to receive health care payments from both Medicaid and Medicaid while their liability case is pending.

In the case of the dual-eligible WC or negligence injured plaintiff, both Medicare and Medicaid will obtain liens against the final settlement sum of the case to the extent that they have each provided health care payments contingent on reimbursement.


Resolving the Medicare or Medicaid Lien

At CompEx, we pride ourselves on our comprehensive Medicare and Medicaid lien resolution services.


Lien Verification

Resolving either or both a Medicare or Medicaid lien begins by ensuring that the liens have been filed accurately within the WC case, and that the charges listed on those documents are accurate to the case.

To ensure each lien is verified, CompEx routinely performs the following services:

  • Reporting the File to Medicare/Medicaid;

  • Checking the record for the existence of a valid Medicare or Medicaid lien and seeking Agency documentation on the value of their lien;

  • Review of detailed charges and removal of unauthorized or erroneous charges;

  • Maintaining the file for three months, with Monthly Updates to our Clients.


Lien Resolution


Once the validity and value of the lien is confirmed, CompEx will negotiate with the lien holder for a reduction in its value, when appropriate, to ensure that our clients are exposed to the lowest costs possible when finally resolving the case.

At CompEx MSA, we take on that practice on behalf of our nation-wide roster of clients:

  • We notify and verify for Medicare and Medicaid when primary payers are identified;

  • When necessary, we also notify Social Security if a claimant may be eligible for SS support;

  • We will analyze conditional payment documents to verify their accuracy;

  • We will review case documents, including medical records and settlement documents, to ensure the rights of Medicare and Medicaid are protected and the claimant and their employer or insurer are in compliance with applicable laws, and
  • In the event there are outstanding liens in the case at its termination, CompEx MSA will work to resolve those so the case can be closed altogether.

At CompEx MSA, we ensure that no employer or insurer overpays Medicare or Medicaid for conditional payments made while the case was ongoing.