The American Association of Nurse Life Care Planners (AANLCP) annual conference is coming together and we are so excited to announce one of our preconference presenters.  Shelene Giles of FIG Services, Inc. will present Medicare Set-Aside (MSA) Education. This Course is taught from a medical perspective. The course includes:

• An overview of Medicare/Medicaid
• Understanding of the Medicare Set-Aside process
• How to request, organize and review medical records that are pertinent to the MSA process
• Effective communication with health care providers
• Determining future medical care to be included in the MSA report
• Identifying Medicare’s coverage and the appropriate costs for future medical care
• Finalizing the MSA report and submission to the Centers for Medicare and Medicaid Services (CMS) for their review/response

These objectives will be taught through independent study, live/interactive class, and hands-on application through the completion of a MSA Sample report. Participants will learn practical skills and utilize hands-on teaching techniques to effectively learn the MSA process. Best of all completion of this MSA Education Course (30 hours) provides the eligibility to sit for the MSCC certification exam through International Commission on Health Care Certification (ICHCC).  Sign up today to reserve your spot!

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There has been much discussion on liability MSA’s.  Are they needed?  Not necessary?  Conflicting reports and a statement by the AAJ has continued to make things complicated.  As a Medicare Set Aside allocator, my position is that Medicare’s interest must be protected per Section 111 of the MSP.  I have outlined a simple equation here for quick reference.

Mr. Synder recented posted a comment on LinkedIn as to his thoughts.  I found it well stated.

Link to statement by AAJ

Nothing in the quotes AAJ cites undermines the insurance industry’s position. Medicare could always seek reimbursement of a conditional payment from the insurance carrier– as well as from the plaintiff’s attorney! The new reporting law allows Medicare to connect the dots and deny payment for treatment which matches the body part code, diagnostic code and occurrence date of the report.
Any plaintiff’s attorney who tells his client that an allocation, i.e., set-aside, is unnecessary puts the client at risk for loss of Medicare benefits, and possibly is putting his/her own E&O insurance on the line.
By Teddy Snyder (Linked IN)

Is there future medical care involved?  Is there a permanent shift of burden?  These things may equate to the need for an MSA (Medicare Set Aside).  Use this equation to determine if an MSA is necessary in your legal case.

FCC + PBS = MSA

The requirement is to protect Medicare’s interest (per SCHIP Section 111)

This can be accomplished formally or informally.  A more formal protection of Medicare’s interest would be in the form of an MSA report.

MSA (where FCC = Future Cost of Care; PBS = Permanent Burden Shift, and MSA = evaluate the need for a MSA/do an MSA report).

As a Certified Medicare Set Aside Consultant, I can assist you with your Workers Compensation or Liability set aside allocation.  Contact me today for any questions, concerns or even to speak to your group about how you can protect yourself as well as Medicare’s interest.

Claimant Mary Ferreira entered into a settlement agreement that included funds for her to establish a Medicare Set-Aside account. The contract stated that Ferreira, not the employer or carrier, be responsible for administering the account. The agreement also provided that the employer/carrier would deposit seed money in the amount of $10,851.08 and $33,694.64 for the purchase of an annuity that would yield $2,154.18 per year, and that amount was final, not subject to change or approval by CMS.

The parties also agreed that if CMS demanded a larger amount, Ferreira would be responsible. Ten months after the settlement was approved, the employer/carrier filed a motion seeking to compel Ferreira to return an “overpayment” of the MSA seed money. The employer/carrier had received correspondence from CMS that the gross amount of the MSA was accurate, but the sums projected for annual deposits were deficient. The employer/carrier had not yet purchased an annuity to fund the deposits. They demanded that Ferreira pay the additional amount so they could buy an annuity that met CMS’s requirements.

The judge of compensation claims granted the employer/carrier’s motion, reasoning the Ferreira had agreed to fund or pay the difference should CMS deem that more money was necessary for future medical expenses. Ferreira appealed.
Analysis: In its majority opinion, the first DCA said that the judge of compensation claims had misinterpreted the settlement contract. Noting in the agreement required Ferreira to pay anything more than the sums that were promised to purchase the annuity to fund the future deposits into the MSA. By not purchasing the annuity as promised, the employer/carrier created a predicament whereby the JCC was forced to rectify the potentially conflicting provisions which, on one hand, provided the annuity amounts were fixed, not subject to change, and not dependant of CMS approval, and on the other hand, made the claimant responsible for any deficiencies later identified by CMS, the opinion said.

Disposition: Reversed and Remanded
To read the opinion, visit WorkCompCentral.com

On June 2, 2009, CMS published new guidelines with regard to prescription drug documentation for Medicare Set Aside allocators.  A copy of the memo can be found on the CMS website.

The memo includes these main points:

• Pricing of prescription drugs is to be based on the current REDBOOK Drug Reference
• Allocators are to use the lowest priced generic drug listed in the reference
• Tapering WILL BE CONSIDERED by CMS as recommended by the treating physician
• Off-label use does not preclude the prescriptions from the allocation and are allowed so long as the drug is FDA approved
• Generic pricing is only used for generics that already exist
• Failure to submit prescriptions results in Medicare’s use of BRAND NAME PRICING
• Those submitting allocations are encouraged to present any evidence helpful towards a determination

This publication stresses that CMS and the WCRC will review the evidence provided on a case-by-case basis with regard to these prescription  drug allocation decisions.  These new guidelines are just one more reason to hire an allocator with the proper medical and legal skills to create persuasive allocations with the best evidence available.

Our staff allocator, Victoria Powell, is a nurse who is familiar with the medical records and the related terminology as well as expectations for treatment.  As a case manager, Victoria understands that the medical records do not always adequately reflect the long term expectations for a patient’s treatment.  She is assertive and with her experience in case management, she can collaborate with the physicians when crafting the allocation to insure it is done correctly and eliminate any unnecessary services. Furthermore, Ms. Powell is certified as a Medicare Set-Aside consultant.  Don’t risk your allocation to a “report writer.”

How do you feel about these new guidelines?  Fair? What problems do you foresee?

The MARC group is seeking transparency between CMS and Primary Plans wtih resprect to conditional payment information, application of state law in the determination of the amount of conditional payments that may be collected, a right of review of CMS decisions on conditional payments, and clear methods of the identification of who is “Medicare eligible” by a primary plan.

Attorny Bill Van Wambeke is the NAMSAP representative on the committee.  If you would like additional information on the issues being raised in Washington, please visit the MARC website at www.marccoalition.com. 

CMS has announced it intends to clarify the language in recovery scenarios where occupational exposures occurred prior to the effective date of the Medicare Secondary Payer Act.  In a recent town hall meeting, Barbara Wright, Bill Decker and others explain some of the reporting requirements and have plans to further clarify the Medicare as Secondary Payor recovery language.  Additional town hall meetings have been scheduled as CMS ramps up for the upcoming mandatory reporting requirements.  Stay tuned..

On May 1st, CMS released a new memo clarifying the Life Expectancy issue for all Medicare Set-Asides (MSA).  Beginning July 1, 2008, all MSA’s must reference the CDC’s Life Expectency Table 1 when determining a beneficiary’s total life expectency.  This table reveals the data for the total US population.  Previously allocators could use other CDC tables which were broken out by race and gender.