By Jill
Breard, RMS Operations Manager
Louisiana Workers' Compensation Corporation
 Which
movie would correctly describe the theme of your claims departments
now that the Centers for Medicare and Medicaid Services (CMS) have
thrown Medicare into the mix? It would have to be a long movie,
with a confusing plot, and quite possibly would be a horror flick.
This article will provide you with some pointers to help define
the Medicare process within your organization. The end result will
vary from carrier to carrier based upon many factors. These include
the level of risk you are willing to accept and the resources you
allocate to your Medicare program.
First, consistency is the key. A Medicare checklist can provide
you with a very quick mechanism to ensure that you obtain a Medicare
Set-Aside (MSA) when needed. Requiring that your claims representatives
complete the checklist for every workers compensation settlement
adds only a couple of minutes to the process. A carefully worded
checklist will cover important issues to include: 1) whether the
claimant is a Medicare beneficiary, 2) whether the claimant is
anticipated to be a Medicare beneficiary within 30 months, and
3) the overall settlement value of a claim (due to CMS's current
$250,000 threshold for claimants who may become Medicare eligible
within 30 months). If the checklist is a required document for
all settlement referrals to your legal department or outside counsel,
then you will have a gatekeeper to ensure the issue is addressed
before your settlement documents are prepared.
A second process consideration is the use of structured settlements.
If your state allows the use of structured settlements for settlement
of workers compensation claims, then this is a tool permitted by
CMS which can save you money. CMS does not permit funding of MSAs
based upon the present value of the claim, but the cost of an annuity
to pay out the medical over time will provide a similar value to
your company. If you require the use of annuities to fund MSAs
over a specific dollar threshold, then you will not only save money,
but just as importantly, you will protect the injured workers who
will need that money for an extended period of time.
Once you have decided that you need the MSA, there are plenty
of vendors to provide the service, so consider having several approved
vendors to prepare your MSAs. There is something to be said about
a little competition to obtain the best product at the best price.
You should also review your volume and determine whether you should
prepare MSAs in-house. A registered nurse can be trained and certified
to perform MSAs in a few months. If that nurse performs 8-10 MSAs
per month, then it is a cost effective endeavor. This nurse can
also be a valuable resource to review MSAs, or to price out medical
procedures for reserve or settlement evaluations for your claims
representatives.
A final recommendation is to have a process or gatekeeper to review
MSAs upon receipt, and then again when settlement negotiations
are underway. There could be weeks between the time you requested
the MSA to the point it is prepared. It could be months before
the claim actually settles from the time the MSA is prepared. During
this time, the workers compensation claim usually continues with
medical care. There can be instances where the MSA includes a recommended
surgery that has been approved and performed while settlement negotiations
were underway. If this occurs, most MSA vendors will revise the
MSA to remove those procedures at no additional cost to you if
within a specified period of time (usually around 6 months). You
also want to be certain that unrelated medical conditions are not
included in the MSA, which can occur if the vendor was not properly
informed of the compensable injury/body parts. I suggest a policy
to carefully review MSAs over a specific dollar threshold for duplicate
procedures and medical conditions not related or not compensable.
There you have it. Recommendations include an MSA checklist, the
use of structured settlements, multiple vendors on your approved
list, consideration of internal preparation, and review of the
completed MSAs. If you address these issues well, you increase
the chances that your movie will have a happy ending. If not, Friday
the 13th, or Mission Impossible?
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