Medicare’s New Set Aside Guide Raises Administrative Concern

On 3/15/22, Medicare amended the language from their January 2022 Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide saying they may deny payment for medical services that are not properly documented and managed.

In Section 4.3, the following language now provides:

“As a matter of policy and practice, CMS may at its sole discretion deny payment for medical services related to the WC injuries or illness, requiring attestation of appropriate exhaustion equal to the total settlement as defined in Section 10.5.3 of this reference guide, less procurement costs and paid conditional payments, before CMS will resume primary payment obligation for settled injuries or illnesses, unless it is shown, at the time of exhaustion of the MSA funds, that both the initial funding of the MSA was sufficient, and utilization of MSA funds was appropriate. This will result in the claimant needing to demonstrate complete exhaustion of the net settlement amount, rather than a CMS-approved WCMSA amount.”

“Notes: This official policy shall apply to all notifications of settlement that include the use of a non-CMS-approved product received on, or after, January 11, 2022; however, flags in the Common Working File for notifications received prior to that date will be set to ensure Medicare does not make payment during the spend-down period.

CMS does not intend for this policy to affect any settlement that would not otherwise meet review thresholds. This comment does not relieve the settling parties of an obligation to consider Medicare’s interests as part of the settlement; however, CMS does not expect notification or submission where thresholds are not met.”

Other revisions include the most frequent reasons for development letters, e-signatures on Consent to Release documents and other administrative procedures.

For a full reading of Version 3.6 of the Guide, please click here >>

To learn more about how our Medicare Lien and Set Aside practices are achieving significant savings for our clients, contact Robert J. Blackburn at This email address is being protected from spambots. You need JavaScript enabled to view it. or 585-586-4530.

By Robert J. Blackburn, Managing Principal, Blackburn Group, Inc., contact him at This email address is being protected from spambots. You need JavaScript enabled to view it..