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29/May/2024

When resolving a workers’ compensation case, the employer looks to see if the injured employee is a Medicare beneficiary and if there will be injury-related future medical care. If the answer to both questions is yes, then they must comply with the guidelines set forth by the Medicare Secondary Payer (MSP) statute.  

With healthcare and Medicare costs on the rise and as the open claim moves through the settlement process, below are some settlement objectives to help keep costs down and stay MSP compliance.      

  • WCMSA Arrangement: Centers for Medicaid and Medicare Services (CMS) recommends this method to ensure that Medicare’s interests are protected when settling a workers’ compensation claim that includes future medical expenses. Note that the WCMSA Arrangements are prepared based on today’s costs. 
  • MSP Compliance: Employers are mandated to follow the MSP statute; it will ensure Medicare compliance when considering Medicare’s interest in the settlement. Failure to do so, you could face legal consequences from breaching the settlement agreement. CMS can also obtain reimbursement of injury related payments made from anyone involved in the settlement, including the worker, workplace, insurance companies and attorneys.  
  • Cost Control: Striving to move an open claim toward settlement in the least expensive manner.  
  • Future Medical Care: Employers can help prioritize the injured employee’s well-being for future medical care after settlement by hiring Medivest for Professional Administration services. Medivest Professional Administration ensures the Medicare Set-Aside (MSA) funds are spent according to the allowable guidelines whereby preserving the MSA dollars.  

 

When to Request a WCMSA? 

A WCMSA is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease that would normally be covered by Medicare. All parties involved in a workers’ compensation case have significant responsibilities under the MSP statute to protect Medicare’s interests when resolving cases that include future medical expenses. 

  • Does the settlement contemplate future medical needs? 
  • Is the injured employee eligible or receiving Medicare benefits? 
  • Has the injured employee applied or re-applied for Social Security Disability Insurance (SSDI)? 
  • Is the injured employee 62.5 years old?  

 

Common WCMSA Cost Drivers 

When a Medivest WCMSA Arrangement is ordered, a Cost Driver Analysis report will be included. A Cost Driver Analysis report identifies the various costs that are driving up the WCMSA amount, such as opioids, injections, and surgeries. Below are some common WCMSA cost drivers when a report is prepared.  

  • Poly Pharmacy: The use of multiple drugs and lifetime pharmacy costs. 
  • Implantable Devices: Devices such as spinal cord stimulators, intrathecal pain pumps which also includes replacement cost and mediation refills. 
  • Surgeries and Replacement Costs: Non planned surgeries. 

 

WCMSA Cost Mitigation Strategies 

When carriers and employers optimize cost mitigation strategies, they can achieve an accurate and timely settlement. The following are examples of helpful strategies.  

  • RX Drug Cost: Reducing prescription drug costs can be used as a pre-MSA strategy by weaning/tapering off some medications, choosing a generic substitution, or using a physician letter (to address changes in medications. 
  • Cost Drivers: Identify treatments or medications that are driving up the total amount of the WCMSA. Review and possibly implement the recommendations provided in the Cost Driver Analyst report to help reduce the WCMSA amount.    
  • Rated Age: If medical records show evidence of a reduced life expectancy, then a Rated Age may be obtained and used when calculating the WCMSA. CMS approves Rated Ages when used in WCMSAs which reduces the life expectancy thus reducing the overall amount of the WCMSA figure 
  • Structured Settlement: Fund the MSA with a structured settlement instead of a lump sum. CMS approves MSAs to be structured and Medicare will cover expenses for the injured employee during temporary exhaustion if the MSA allocation was approved by CMS. Also, utilizing a structure can provide significant cost savings for the funding party compared to a lump sum payment.  

 

Ready To Order Your WCMSA? 

Begin by completing an online referral by clicking here and upload the following documents.  

  • Most recent 2 years of medical records 
  • Most recent 2 years of Rx invoice 
  • Most recent 2 years of indemnity payouts (Work Comp cases only) 

 

About Medivest  

Medivest has worked with carriers and employers for over 2 decades to understand their unique needs and responsibilities to their injured workers. Every WCMSA Arrangement is produced by a highly trained nurse that possesses a wealth of knowledge and experience in the preparation of these reports. We understand that creating and maintaining a WCMSA can be complex, let Medivest prepare your next report. Our nurses and staff hold industry certifications or designations including CMSP, CMSP-F, CPC, MSCC, CSSC, JD, RN, and BSN.  

 


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22/May/2024

The Centers for Medicare & Medicaid Services (CMS) has released the Self-Administration Toolkit for WCMSAs version 1.5 on May 15, 2024.  The Toolkit replaces Version 1.4 which was released on July 3, 2023.

To download the new Self-Administration Toolkit for WCMSA Version 1.5 click here.

Self-Administration With Additional Help

For injured parties who are considering self-administration, but who also want additional consultation on the process, Medivest provides a Self-Administration Kit. With purchase of the Medivest Medicare Set-Aside Self-Administration Kit, the injured person will receive a one-hour consultation on the proper administration of a Medicare Set-Aside account, covering topics including:

    • Where to deposit and hold Medicare Set-aside funds
    • Which expenses are allowed to be paid from a Medicare Set-Aside account
    • What rates must be used to negotiate and pay for expenses
    • How to annually report the Medicare Set-aside to the CMS
    • What to do if the MSA funds exhaust temporarily or permanently
    • How to discuss a Medicare set-aside with a medical provider
    • What are the tax implications of interest earned on Medicare Set-Aside funds

     

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions about self administration, professional administration or anything else regarding rules and recommendations from CMS, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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09/Apr/2024

On April 1, 2024, Centers for Medicare & Medicaid Services (CMS) updated the MMSEA Section 111 Non-Group Health Plan (NGHP) User Guide version 7.5. It has been posted to the NGHP User Guide page on CMS.gov.  The NGHP User Guide version 7.5 replaces Version 7.4 which was released on January, 30, 2024.

To download the updated MMSEA Section 111 NGHP User Guide 7.5 click here.

MMSEA III- April 1, 2024 – NGHP User Guide Downloads 7.5

Updates:  There are no changes for this version

Updates:  There are no changes for this version.

Updates:   The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Section 6.5.1.1). As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).

Updates:  The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Sections 6.1, 6.4.4, and 6.5). As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).

Updates:  Beginning April 4, 2025, CMS will collect information about WCMSAs through Section 111 reporting. To support this effort, related fields have been added to the Claim Input File Detail Record; note that as the current file layout is unchanged, all the not-yet-implemented codes are marked with an asterisk (*) in the field number to distinguish them from the those in the current file layout. Once they are in effect, all the asterisks will be removed and the fields that follow them will be renumbered. Error codes related to these fields have also been added to the Claim Response File Error Code Resolution Table (Appendix A and Appendix G).

Updates:  The end-of-line character has been clarified for files using HEW software (270/271 File Translation).

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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02/Apr/2024

The Centers for Medicare & Medicaid Services (CMS) released a revised Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (“Reference Guide”) Version 4.0 on April 1, 2024. This Reference Guide replaces Version 3.9 which was released on May 15, 2023. There are a few notable changes when comparing the two Reference Guides.   

Changes in This Version 4.0 of this Guide Include the Following Changes:

  • Instruction specific to beneficiaries has been added to encourage them to use their Medicare.gov access to the portal for the most efficient method of submitting attestations (Sections 11.1.1 and 17.5). This user-friendly mechanism which allows CMS to gain potentially more MSA spending information than it has received via traditional mailing, may lead to CMS denying more future medical claims or potentially considering whether recovery of future medical payments that slipped through the cracks is viable. 
  • The CDC Life Table link was updated (10.3) – available to view here.

 

To download the new WCMSA Reference Guide v4.0 click hereThis guide reflects information compiled from all WCMSA Regional Office (RO) Memoranda issued by CMS, from information provided on the CMS website, from information provided by the Workers Compensation Review Contractor (WCRC), and from the CMS WCMSA Operating Rules. The intent of this reference guide is to consolidate and supplant all historical memoranda in a single point of reference. Please discontinue the reference of prior documents.

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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25/Mar/2024

On Tuesday April 16, 2024, Centers for Medicare & Medicaid Services (CMS) will be hosting a second webinar regarding the expansion of Section 111 Non-Group Health Plan (NGHP) Total Payment Obligation to Claimant (TPOC) reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) information. After the first webinar in November, CMS received additional questions and feedback from the industry. The intent of this webinar is to ensure that RREs will be prepared for the change once implemented.

With that in mind, this webinar will include a background recap, summary of technical details, updated timelines and CMP impacts. The presentation will be followed by a question and answer session. Because this expansion impacts reporting of WCMSAs, it is strongly recommended that Responsible Reporting Entities (RREs) that report Workers’ Compensation settlements attend.


 

Date:  April 16, 2024
Time:  2:00 PM EST

Webinar Link: https://cms.zoomgov.com/s/1610015349?pwd=NHcza3NhcDlCdjM0cVhENWlNcFBjZz09
Passcode:  750766

Or to connect via phone:

Conference Dial In:  1-833-568-8864
Conference Passcode:  161 001 5349


 

Additional information about the most recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients or your company, please contact Medivest or call us at 877.725.2467.

 


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26/Feb/2024

On Friday, February 23, 2024, Centers for Medicare & Medicaid Services (CMS) published an alert regarding the upcoming change to Section 111 reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) amounts for Workers’ Compensation settlements meeting the $750 threshold regardless of whether the WCMSA was submitted to CMS for approval or not.

“All MSA funding for WC settlements shall be reported regardless of whether or not an approval was previously sought from the CMS. This change will be prospective for the Total Payment Obligation to Claimant (TPOC)s on or after the implementation date. For example, records submitted on a production file with a TPOC date on or after April 4, 2025, will be subject to the new edits.”

Please note that testing of the new fields will be available as early as October 7, 2024. The full alert is available at in the Download section of the NGHP Alerts page here.

For Additional Information

Count on Medivest to help keep you up to date with the constant updates, guidance, and rule changes related to CMS’s enforcement of the MSP on a regular basis. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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15/Feb/2024

CMS has announced that it is maintaining the $750 Section 111 reporting threshold and the $750 Medicare Secondary Payer statute’s (MSP) recovery thresholds for 2024. CMS’s announcement that can be found here.

The CMS notification states, “Beginning January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals.

This means that entities are not required to report, and CMS will not seek recovery on settlements, as outlined above. Please note that the liability insurance (including self-insurance) threshold does not apply to settlements for alleged ingestion, implantation, or exposure cases.

Additional information regarding the methodology used to determine the threshold is also provided at the link to the announcement.

For Additional Information

Medivest will continue to monitor news and updates from CMS, and will keep its readers up to date when important announcements are made. For questions about this chart or any other recent updates, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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31/Jan/2024

The January 18th, 2024 webinar hosted by Centers for Medicare & Medicaid Services (CMS) entitled Medicare Secondary Payer and Certain Civil Money Penalties (Non-Group Health Plan) is now available in the Download section of the What’s New page on CMS.gov. The webinar can be viewed in its entirety, or you may download the materials covered in PDF format by clicking here.   

Medivest will continue to monitor news and updates from CMS and will keep its readers up to date when important announcements are made. For questions regarding the information presented in this webinar or any other recent CMS updates, please reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467. 

 


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23/Jan/2024

On January 22, 2024 the Centers for Medicare & Medicaid Services (CMS) released their data for the Top 10 Section 111 Non-Group Health Plan Reporting Errors July – December 2023. The chart with the list of errors and their rank can be viewed below. A downloadable PDF of this chart along with an explanation of the error codes can be viewed here at the CMS website.

Medivest will continue to monitor news and updates from CMS, and will keep its readers up to date when important announcements are made. For questions about this chart or any other recent updates, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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22/Jan/2024

On January 10, 2024, the U.S. Department of Labor published a final rule, revising its guidance to employers and workers to help determine if a worker qualifies as an employee or an independent contractor (IC) under the Fair Labor Standards Act (FLSA).  The final ruling explains that the economic reality test is comprised of six-factors that are a guide to conduct the totality-of-the circumstances analysis to determine economic dependence. The new ruling takes effect March 11, 2024. To view the final ruling, click here 

Misclassification Issues 

Employers need to distinguish between employees and independent contractors when considering eligibility for workers’ compensation. Correctly distinguishing between employees and independent contractors is crucial for legal compliance, cost management, liability avoidance, and ensuring workers receive the appropriate benefits and protections. Misclassification can have significant financial and legal consequences for employers. 

What is the Economic Realities Test?  

The US Department of Labor uses an economic realities test to help employers comply with the law, reduce the risk of employee misclassification, and to help determine if a worker is classified as an independent contractor or as an employee. This test consists of six-factors that are all weighed against each other. All factors should be considered.  No single factor determines a worker’s status.  No one factor or combination of factors is more important than the other factors.  This test considers the totality of the circumstances of the working relationship. Below are the six (6) factors. 

  1. Opportunity for profit or loss depending on managerial skill, 
  2. Investments by the worker and the employer, 
  3. Permanence of the work relationship, 
  4. Nature and degree of control, 
  5. Whether the work performed is integral to the employer’s business  
  6. Skill and initiative 

 

About Medivest 

Since 1996 Medivest has been helping our clients navigate the complexities of MSP compliance.  We offer settlement solutions for workers’ compensation and liability settlements. Count on Medivest to help keep you up to date with the constant updates regarding Federal Register rulings, Medicare Secondary Payer legislation and changes related to CMS’s enforcement of the Medicare Secondary Payer.  For questions, feel free to reach out to a Medivest representative in your area by clicking here or call us direct at 877.725.2467. 

 


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