How to Prevent Treatment Denials with Medicare Set-asides (MSA)

When navigating the complexities of personal injury settlements, it’s crucial to be proactive about Medicare Set-asides (MSA) and avoid potential treatment denials. The best way to do that is to understand MSAs from the beginning.

What is Medicare Set-Aside (MSA)?

First, let’s answer the question of What is MSA? A Medicare Set-Aside (MSA) is a financial arrangement specifically designed to cover future medical expenses for individuals involved in personal injury settlements, ensuring that treatments that Medicare would otherwise cover are accurately projected and accounted for. This mechanism aims to protect Medicare’s interests by ensuring that the funds designated for future medical treatments related to the injury are utilized before Medicare is asked to pay. It’s a proactive approach, guided by specific protocols and review thresholds set by the Centers for Medicare & Medicaid Services (CMS). Given the complexities and potential denials associated with MSAs, beneficiaries are often advised to seek professional assistance to navigate and manage their MSAs effectively.

Understanding the MSA Landscape

The prevailing assumption has been that merely having an MSA is adequate. However, a white paper by Ametros, a professional administration company, suggests otherwise. Jason Gallant, one of the authors, and John Kane, Ametros’s Vice President of Strategy, shared vital insights from their research, which can be instrumental for personal injury settlements.

1. Awareness of Denial Precedents: In 2018, a surprising denial from Medicare was observed for an individual self-administering their MSA. The denial specified that the claim was rejected because of the existence of WCMSA funds. This incident prompted research to understand the frequency of such denials.
2. Understand Medicare’s Standpoint: Between 2018 and 2020, an average of 11,000 members per year faced at least one denial because the WCMSA should’ve been the primary payer. Medicare’s objective isn’t to discourage but to guide beneficiaries to use WCMSA funds properly.
3. Opt for Professional Administration: Relying on expert administration can be the difference between successful claims and denials. Medicare strongly advocates for professional administration, emphasizing the significance of leveraging these funds correctly.

The Role of CMS in MSAs

Centers for Medicare & Medicaid Services (CMS) play an essential role in the MSA process, making their understanding pivotal in personal injury settlements.

MSA Creation: John Kane clarified that MSAs project future medical expenses, ensuring that treatments covered by Medicare are accurately forecasted.

CMS Review Thresholds: CMS has specific thresholds for case reviews, such as a $25,000 settlement for Medicare beneficiaries or over $250,000 with a reasonable expectation of Medicare enrollment within 30 months.

Key Takeaways for Personal Injury Settlements

Stay Informed: Knowledge of how Medicare operates, and its relationship with MSAs is pivotal. This can empower beneficiaries to navigate the system effectively.

Seek Professional Assistance: It’s advised to consult professionals who understand the intricacies of MSAs, ensuring claims are structured correctly and avoiding potential pitfalls.

Proactive Management: Given the existing workflows Medicare has in place, proactive management of the MSA can prevent unnecessary denials.

Personal injury settlement recipients can protect themselves from potential treatment denials with MSAs by being informed, seeking professional guidance, and managing their MSA proactively. Knowledge is power; in this context, it’s also the best defense.

To find a structured settlement consultant to help you navigate the MSA landscape, you can start your search here: Structure Settlement Consultant Directory.

To listen to our podcast on this topic with our partner Ametros, click here:  Ringler Radio Episode.

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