Years ago, the Center for Medicare Services (CMS) discovered in an audit $48 million they had paid out for treatment that had already been paid for in a settlement from another payer. Since then, a long process has been started by CMS to control these costs.
First, they required money be set aside to cover these future medicals and Medicare’s interests. They set up a process to determine how much should be set aside. Medicare Set-Aside (MSA) allocation compliance was a major concern for payers.
Then, CMS required that payers report claims to them where the patient could possibly be on Medicare, or pay a $1,000 a day penalty. This was to prevent conditional payments by CMS. That drove compliance from the payers.
CMS has now tagged this data to the patients’ working files. We are seeing CMS Explanation of Benefits with denials due to the patient having a settlement or other coverage (see below). This means that we are entering the final, and actual important phase of protecting CMS through the MSA process – post settlement compliance.
As patients have their Medicare payments denied, they will start coming back to their attorneys or payers who handled their workers’ compensation, auto or liability claims and will start demanding help with compliance. This will create more awareness over time for the need for POST settlement compliance and will drive up the percentage of claims that require MSA administration assistance.
If you are a payer and do not have processes to assist claimants with post settlement MSA administration, it is time to put this solution in place.