While development letters (CMS letters asking for additional information for a submitted MSA) have slowed over the last several months, we are still seeing them, nonetheless. 

For those of us who have been doing Medicare Set-Asides for over a decade, CMS’ pricing of prescription drugs has been a difficult pill to swallow. 

This Ask Amy topic comes from one of my workers’ compensation cases.

The Centers for Medicare and Medicaid Services (CMS) just published version 3.0 of their Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide.

I received several calls in the last couple of months, mainly from Claimants’ attorneys, asking if I know anything about “evidence-based MSAs.”

Our office recently received several questions regarding the proposed Explanation of Benefits (“EOB”), as well as the current Department of Insurance Rules concerning electronic billing in Workers’ Compensation claims.

A few months ago, we submitted an MSA in a case where Lyrica was being prescribed “off-label” for a diagnosis of lumbar radiculopathy.  CMS included it in the MSA.  The inclusion of Lyrica inflated the MSA astronomically, and nearly prevented the case from settling.  I received this question:  “How can the rules just change like this?  Isn’t there some sort of advance notice required for changes like this?  This just isn’t right!”

Question:  We recently learned that an injured worker is using an American citizen’s Social Security number, and that American citizen is a Medicare beneficiary.  The worker using that Social Security number is technically undocumented, however, and is 64 years old.  What do I need to do in my settlement to remain in compliance with the Medicare Secondary Payer Act?

Question:  How much does the Medicare Secondary Payer program really impact the Medicare program?  Does it really make it more likely that Medicare will be around when I am old enough to qualify for this entitlement program?

I have a claimant who is currently 62 years and 1 month old.  The total settlement is over $250,000.   Does this meet the CMS review threshold? If not, are we “safe” by not submitting?