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Medicare Set Aside Compliance – Medicare is Taking Action

As the Centers for Medicare and Medicaid Services (“CMS” or “Medicare”) ratchet up their active monitoring of Medicare Set Aside (“MSA”) accounts, using a professional administrator to help make sure reporting is in order is becoming even more critical. 

There is no doubt that CMS is taking compliance with the Medicare Secondary Payer Guidelines more seriously these days.  Just take a look at the sequence of initiatives they have put into motion over the past several years to prevent wrongful payments from the Medicare fund – from implementing mandatory reporting to earlier recovery processes to expanding the scope of MSAs to liability and non-fault cases. (see Exhibit A for a brief timeline of Medicare’s actions)

At Ametros, we manage MSA’s for thousands of injured individuals so we have first-hand experience responding to Medicare’s actions and mitigating the issues that arise with the accounts. Below are a few examples of situations where we have seen Medicare take action and we have helped injured parties resolve the issues:

Recently our team at Ametros received a phone call from Susie, an injured individual who had settled her case last year and found our website by searching online. She was looking for help with her Workers Compensation Medicare Set Aside (“WCMSA”) and called us with a representative from Medicare on the line. Medicare was asking to be reimbursed for treatments over the past year they had paid for that should have been paid out of Susie’s WCMSA account. Until reimbursement for the older bills was sorted out, Medicare was denying all of Susie’s medical bills, regardless of whether it was related to her injury or not. After explaining to Susie what needed to be done and how our services would help her, she became a CareGuard member. Our team then worked with Medicare to reimburse them for her previous treatments with her WCMSA funds and to help Susie track and fulfill all of her reporting going forward.

On another case earlier this year, we got a call from Emilio, a member on our CareGuard platform for whom we were completing MSA reporting. Even though we had been submitting Emilio’s reporting and bills accurately to Medicare, Emilio had been accidentally showing his Medicare card instead of his CareGuard card at one of his doctor’s offices. This meant the bill was directed to Medicare for payment instead of to CareGuard for payment out of his MSA funds. The doctor had attempted to bill Medicare for his office visits but Medicare detected that the visits were related to Emilio’s MSA and denied to pay for the treatment.  Medicare told Emilio that he needed to use his MSA funds first. Once our team understood the issue, we were able to sort it out, pay the bills and coordinate with Emilio’s doctor going forward to remedy the situation so that he could continue his treatments.

We have also seen on several occasions situations arise where the original Section 111 reporting sent to Medicare by the payer (see Exhibit A below for more on Section 111) includes a diagnosis that is later denied or left out of the settlement. This can create confusion for injured parties when they try to get coverage for that diagnosis after they settle. 

For example, a member of ours, Gabriel, had an initial Section 111 report that referenced a knee and foot injury. However, when Gabriel’s case settled later on, it only included settlement for the foot condition and the knee was not accepted as part of the injury. Sometimes the settlement report via Section 111 takes time to update and Medicare may not receive the latest information on the settlement before the injured person tries to get treatment through Medicare. This happened to Gabriel and caused Medicare to deny the bills received related to his knee, telling him instead that the injured party should use their MSA settlement funds before billing Medicare. Our team cleared up the confusion with Medicare and let them know that knee was not covered in his settlement.  At Ametros, we have a team that troubleshoots these types of issues to coordinate with Medicare to make sure all the information is up to date.

Many times, there is the misconception that Medicare is “asleep at the wheel” and overlooking many of these issues, and that they will not deny bills in the first place or follow up for reimbursement later on. At Ametros, we have seen Medicare’s contractors become consistently better at their recovery and denial tactics.  Medicare is catching up, with more resources to check into billing both pre- and post-settlement.

For instance, one indication we have seen of increased oversight is Medicare’s increased responsiveness to fund depletion letters. It is fairly rare, but when our members MSA funds are actually depleted, our team at Ametros files an attestation to Medicare on their behalf according to the guidelines.  While several years ago, we rarely got a response from Medicare, today we receive a response to over 1 in 5 of our attestation reports, usually accompanied with questions from Medicare.

This increased vigilance means more work for injured parties to ensure they are spending the funds appropriately and properly completing the annual reporting. After settlement, injured parties have the difficult task of determining which medical treatments are going to be covered by the MSA, and which are going to be billed to Medicare. For the average person, this task can become confusing very easily. Injured parties have been through enough, they do not need the added stress of complex reporting and dealing with denials from Medicare.

This is where a MSA custodial account with Ametros can provide much-needed relief. By working with a professional administrator and setting up a MSA custodial account, injured parties are no longer left with the responsibility of completing complicated reporting and determining how treatments should be billed. At Ametros, our team works daily with Medicare to resolve these issues and answer questions.

Want to find out how we can help you or your client?  Even if there are issues after settlement, our team can help.

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