As most personal injury attorneys now know, Medicare’s interests must be considered when settling a workers’ compensation or liability claim, where the claimant is either on Medicare, or has a reasonable expectation of being on Medicare within thirty months of the settlement. The most effective way to consider Medicare’s interests is to incorporate a Medicare set-aside (MSA) into the settlement.  In certain circumstances, the Centers for Medicare and Medicaid Services (CMS) will review the Medicare set-aside to determine whether it adequately considers Medicare’s interests.  Although getting a Medicare set-aside approved by CMS is the best way to insure they agree it adequately considers their interests, this process can be very time consuming if not done correctly.

The process typically begins with a referral to a Medicare set-aside vendor or consultant. Most vendors and consultants can complete the Medicare set-aside allocation within a week or two of receiving a copy of the medical records and prescription history.*  If the MSA is going to be submitted to CMS, the parties will need to provide the vendor with other documents including a payment history from the insurance company, a copy of the proposed settlement documents and Consent to Release signed by the claimant.  Failure to provide the vendor with all of the necessary documents and authorizations can delay the submission process. 

Once the MSA allocation is completed and all documents are received, the vendor can submit the MSA to CMS.  CMS is presently averaging between four and six months to provide a response.  Failure to provide CMS with all the necessary information and documentation at the time of submission can result in a “development request” from CMS which can delay the approval process further. A development request typically asks for updated medical records, a current payment history or evidence of the prescriptions the claimant is taking.  If the development request is not properly responded to within thirty days, CMS will close its file, and the submission will go into administrative limbo.

Under certain limited circumstances, CMS will perform an expedited review which can result in a quicker approval time.  An expedited review can be requested by the submitter, but only if it can be shown that the standard review time would pose a substantial financial hardship to the claimant.  A substantial financial hardship can be shown with evidence of eviction or foreclosure.  Please note that an upcoming trial date is not enough to obtain an expedited review.

The best way to have the MSA approved in a timely fashion is to utilize a vendor that will complete the MSA as quickly as possible, follow-up with the parties regarding any outstanding documentation and avoid the dreaded “development request.”

If you have any questions or need assistance with getting a Medicare set-aside approved, please feel free to call us at (866) 306-9423.

* MSA Services, LLC is proud to have one of the quickest turnaround times in the industry.  Our Medicare set-aside certified consultants can have the allocation ready for submission in as little as three business days from the receipt of all necessary documents. 

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