Medicare Set-Aside

If you anticipate settling a workers’ compensation or personal injury case, and the client is expected to require future medical treatment and/or medications related to the injury or accident, an MSA is the best way to document that you’ve considered Medicare’s interests.

  • Mackler Associates provides a comprehensive analysis of prior treatment and present status
  • Projects reasonable and necessary Medicare-covered items and services, including prescription medications, in compliance with CMS guidelines
  • Calculates corresponding costs at state fee schedule or usual and customary rates
  • Can be done on both workers’ compensation and personal injury cases
  • Obtains rated ages when indicated
  • Can be done on individuals living in any location
  • Calculates annuity information

How We’re Different:

  • Mackler Associates does much more than complete the standard “cookie cutter” MSA.  Instead, we thoroughly analyze the issues that impact your MSA, and when indicated develop a plan to clarify and resolve these issues BEFORE the MSA is completed.
  • Mackler Associates ensures that your MSA accurately reflects the unique set of circumstances that are specific to your claim.
  • 7 business day turnaround for MSA’s
  • RUSH MSA’s completed in 2 business days, at no additional cost, on request
  • Costs of non-Medicare covered services and medications provided, at no additional cost, on request
  • Competitive pricing

Call Mackler Associates for a Free Consultation.  Experience you can rely on.
For more information, please call (413) 391-0856 or e-mail Sandra@macklerassociates.com.

Additional Services

Consultation

  • Analyzes medical records and identifies potential barriers to CMS approval
  • Makes recommendations to clarify/resolve identified issues
  • Identifies missing or inadequate records
  • Communicates with physician and/or attorney when indicated, to clarify future treatment recommendations

 

MSA Screen

Not ready for a formal MSA, but need to have a better idea of your potential MSA exposure?

Mackler Associates will identify the high-priced medications and treatments that will impact your MSA, and will provide you with a preliminary estimate of lifetime costs, so you are prepared to make sound decisions.

 

Medication Review

Mackler Associates focuses on medications because CMS will include medications that the claimant is utilizing at the time of the MSA (or in the two years prior to the MSA), and will assume that they will continue throughout the claimant’s life expectancy. 

MEDICATIONS ARE TYPICALLY THE BIGGEST COST DRIVER OF MEDICARE SET-ASIDES

Medication Reviews, including pharmacist consultation with prescriber, are designed to clarify and/or modify the medication regimen.

Why clarify?

  • Physicians are often unaware of what their patients are actually filling and how often they are filling it.
  • People often stop filling medications because they don’t find them effective, and don’t tell their physicians (who don’t ask).
  • Physicians often do not specify the work-related versus unrelated medications.

Start early!  When medications change, it takes time to establish a new prescribing pattern.  CMS will not assume that the change will occur, based on only a physician’s report, and will need to see evidence that the medication change has occurred and is ongoing.

Once a new prescribing pattern is established, the MSA can be formalized, often with a significantly lower result.

Here are a couple of examples of what we’ve accomplished:

EXAMPLE

The case involved a claimant on multiple medications.  Every medical report from the treating physician listed the same medications, including dosage and frequency.  However, when we analyzed the detailed pharmacy payment history, we determined that one particular medication had not been filled in four months.

We recommended contacting the prescriber, sharing the pharmacy payment history, and asking the physician to clarify whether the claimant was still taking this particular medication.

OUTCOME

At the next follow-up visit, the physician found out that the claimant had in fact stopped using this medication due to side effects, and confirmed that the claimant’s other medications were managing his symptoms adequately.  The physician provided documentation accordingly, and this particular medication was eliminated.

MSA Reduced by: $48,000

 

EXAMPLE

After thorough analysis of a claimant’s two long-term medications, we determined that medication #1 was being prescribed at twice the recommended dosage for chronic musculoskeletal pain, although there is no evidence that this dose provided any additional benefit.  Medication #2 was being prescribed as a brand name, although the generic version has been available for many years.  The claimant had told the prescriber that he had a pre-existing condition that required that he remain gluten-free, and that it was therefore necessary that all of his medications be brand name.

OUTCOME

We enlisted the assistance of our pharmacist consultant, Dr. Steven Miller.  Dr. Miller’s research included consulting with a representative of the manufacturer of medication #2, who confirmed that they could not state that their product was gluten-free.  Dr. Miller spoke with the prescriber directly.  The prescriber agreed that the dosage of medication #1 could be gradually reduced to the recommended dosage.  Regarding medication #2, the prescriber was unaware that brand name medications are not necessarily gluten-free, just as generics do not necessarily contain gluten.  The prescriber agreed to change both medications, and subsequent monitoring confirmed that the claimant was filling the newly agreed-upon medications.

MSA Reduced by: $120,300

 

MSA Submission to CMS

Mackler Associates prepares submission documents and all required attachments, and insures that the documentation is as up-to-date and thorough as possible.  Average turnaround time for CMS to complete a review is 45 days.

NOTE: CMS approval of a proposed Workers’ Compensation Medicare Set-Aside (WCMSA) is not required.

There are no statutory or regulatory provisions requiring that you submit a WCMSA amount proposal to CMS for review.  If you choose to use CMS’ WCMSA review process, the Agency requires that you comply with CMS’ established policies and procedures in order to obtain approval.*

* WCMSA Reference Guide, May 29, 2014

CMS will review a proposed WCMSA when the following workload review thresholds are met:

  • The claimant is a Medicare beneficiary at the time of settlement and the total settlement amount is greater than $25,000.00; or
  • The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the total settlement amount is greater than $250,000.00.

A claimant has a reasonable expectation of Medicare enrollment within 30 months if any of the following apply:

  • The claimant has applied for Social Security Disability Benefits
  • The claimant has been denied Social Security Disability benefits but anticipates appealing that decision
  • The claimant is in the process of appealing and/or re-filing for Social Security Disability Benefits
  • The claimant is 62 years and 6 months old
  • The claimant has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD

 

Medical Cost Projection

  • Projects future injury/accident-related medical costs, calculated at workers’ compensation or usual and customary rates, for reserve setting or settlement negotiation.

 

Conditional Payment Research & Negotiation

  • Determines if conditional payments have been made, obtains details and determines relatedness of those payments, and negotiates as needed.

 

Social Security and Medicare Entitlement Status Determination

  • Obtains required release and verifies Social Security and Medicare entitlement status from the Social Security Administration.

 

Medicare Set-Aside Update

  • Reviews all new medical records and payment histories since prior MSA was completed, and revises MSA as appropriate.

 

Fees

  • Fees for Medicare Set-Asides and additional services are dependent on the complexity of each case and required services.
  • Consultations available always at no charge.
  • Fees for all services will be provided at time of referral.

 

Call Mackler Associates for a Free Consultation.  Experience you can rely on.
For more information, please call (413) 391-0856 or e-mail Sandra@macklerassociates.com.