Medicare Set Aside Workers Compensation Project in California

Recently, one of our customers requested a Medicare Set Aside (MSA) with a Centers for Medicare and Medicaid Services (CMS) approval be completed on a Workers Compensation claim. The parties settled the claim for $225,000, plus defendants funding of a self-administered Medicare Set Aside at a cost to defendant not to exceed $44,000. Our Client advised if the cost of the MSA was in excess of $44,000, either party could void the agreement or they would negotiate further.

This case involved an established claim for an injury to the lumbar spine. While working for the employer, the claimant alleged that he sustained a compensable injury to his back when he fell from a scaffold. The insured had accepted compensability for the incident of the claimant's low back claim. The claimant had been examined, evaluated, diagnosed, and treated by a number of authorized doctors including three orthopedists and by one physiatrist and a pain management doctor. None of the orthopedics recommended surgery.

We had a Medicare Set Aside (MSA) completed for our client. Based upon the claimant's current medical status to date and frequency of treatment a projected medical need of $41,000 was determined. We subsequently conducted a Lien search and found no benefits were paid to the claimant. We submitted our MSA to CMS for approval which we were able to secure for our client within 35-40 days! CMS established the prescription benefits set aside based upon "as needed" use of the medication which significantly lowered the Part D Set Aside. CMS approved our Medicare Set Aside (MSA) allocation for only $20,000. This resulted in an immediate earnings surplus gain of approximately $21,000 which went straight to the client's bottom line. The client was overjoyed and recognized the result as an extremely high quality outcome for their claim management program. The response from the client is that "you will get all my MSA's and I will spread the word to all my colleagues so that they know what a great job you all do."