By: Gregory Lisowski, J.D., MSCC of MSA Services, LLC
Submitting a Medicare set-aside to the Centers for Medicare and Medicaid Services (CMS) for approval can be a very thorny process. CMS is extremely particular on how they want the proposal submitted for review. Failure to follow their required procedure closely can result in significant delays or even rejection of the submission. Thankfully, CMS has issued some guidance in the form of policy memorandums to help a submitter successfully navigate the minefield that is the Medicare set-aside review process. These memorandums are very specific about what information and documentation must be included in the MSA submission. It is extremely important for a submitter to include all the necessary information and documentation in the manner that is required.
A submission must always include medical records from all treating physicians for the last two years of treatment for the subject injury. Please note that the last two calendar years is not necessarily the same as the last two years of treatment. It should also be pointed out that CMS requires the treatment records even if the carrier has not paid for the treatment. If it is questionable whether the treatment is related to the injury, it is recommended that you send those records along with an explanation as to why you feel they are unrelated. It is also important to make sure the last treatment date referenced in the life care plan, carrier letter or payment history is accompanied by a record that matches that date. You are always free to send in whatever documentation you believe is necessary and helpful, however, the initial report of injury, records relating to major surgeries, and medical records for the last two years of treatment for the work injury are the only medical records CMS requires.
You are also required to provide recently-dated pharmacy printouts or statements from all treating physicians that specify the medication, strength/dosage and frequency. If you believe the medications the claimant is taking are not related to the injury, send the medication information along with any explanation you believe is necessary. It is also best to include documentation from the treating physician as to why the medication is not related to the subject injury. If the claimant has used more than one pharmacy or has had more than one treating/prescribing physician, make sure all sources have been tapped for the information.
The submission must also include a payment history from the workers’ compensation insurance carrier that includes all medical, indemnity and expenses paid for at least the last two years. The payment history must be dated within the six month period prior to submission and include the payment date, payee, date of service and amount.
The submission should include a cover letter, called the “submitter letter”, that specifies the gross total settlement amount as a single lifetime number. If annuities are involved, use the lifetime payout amounts in the total instead of annuity purchase price and include the annuity rate sheet to support your calculation. Include in the total all attorney fees, proposed set-aside amounts for medical services and/or prescription drugs, settlement payments of past medical expenses/liens, amounts for non-Medicare medicals, settlement payment of any Medicare conditional payments, amounts of previous settlements, any third party liability settlements, and amounts of any waived or forgiven liens/expenses at settlement. Making references to attachments without stating the actual settlement amount will generally result in a development request.
The submitter letter must also state the proposed lifetime, not the annual set-aside amount and should clearly show how much of that is for medical services and how much is for prescription drugs. Make sure the proposed medical expenses plus the proposed prescription drug expenses add up to the total proposed amount. If annuities are proposed for the MSA, use lifetime payout amounts instead of annuity purchase prices, and include the amount of the proposed seed money/initial deposit.
If you intend on using a rated age to support a reduced life expectancy, you must calculate the median rated age for all quotes received. The submission must also include the following language: “Our organization certifies that all rated ages we have obtained and/or have knowledge of regarding the claimant, and generated at any time on or after the Date of Incident for the alleged accident/illness/injury/incident at issue, have been included as part of this submission of a proposed amount for a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) to the Centers for Medicare and Medicaid Services.” CMS will not accept any variation or substitute wording.
If you receive a post-submission development letter from CMS that requests further information, it is important make sure each item in the request is addressed timely, especially the items printed in all caps. The submitter should not resubmit prior documents unless it is confirmed that they were not received. If you are unsure what is needed, call the Workers’ Compensation Review Center (WCRC) to see if what you are sending will be sufficient. Failure to provide the requested information within thirty days of the development letter will generally result in the WCRC closing their file. Insufficient replies received after the closeout letter has been issued are generally not acknowledged due to resource limitations. It is strongly recommended that you call the WCRC two to three weeks after sending information to make sure your additional documentation was received and is sufficient.
Getting a Medicare set-aside through the CMS review process can be a difficult task. Hopefully, incorporating the foregoing tips will help your submission get through the CMS review process more smoothly.
If you have any questions about this topic or need assistance with a Medicare set-aside submission you can contact Gregory F. Lisowski, J.D., MSCC at (203) 437-7140 or firstname.lastname@example.org.
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Source by Gregory F. Lisowski