Longer Medicare set-aside waits seen as new contractor sought

The Centers for Medicare and Medicaid Services call for contractor bids to review workers compensation Medicare set-aside accounts could result in longer wait times to complete such reviews, experts say.

CMS expects to release its contractor solicitation next Tuesday for a one-year contract that could be extended to 2021, according to a presolicitation the agency posted online last week. The contract is expected to be awarded in June.

It “seems that CMS is scanning the market for a better deal,” said Rita Wilson, CEO of Delray Beach, Florida-based Medicare secondary payer compliance firm Tower MSA Partners L.L.C., in an emailed statement.

Erie, Pennsylvania-based Provider Resources Inc., which could not immediately be reached for comment, has reviewed Medicare set-aside agreements since 2012.

Federal rules require insurers and self-insured employers to repay CMS for a Medicare beneficiary's medical treatment related to workers comp or liability cases. Medicare set-asides are accounts used in workers comp settlements that pay for an injured worker's future medical care when that person is eligible or expected to be eligible for Medicare.

CMS uses an outside contractor to conduct the approval process for voluntary set-asides, which determines how much money should be placed into the set-aside account.

Insurers and employers that don't adequately cover such costs could be liable to pay a claimant's future medical bills if the settlement money runs out.

Experts say Provider Resources' turnaround time was a large improvement over that of Annapolis Junction, Maryland-based Lifecare Management Partners L.L.C., which handled the reviews prior to 2012 with turnaround times of six months to a year.

Provider Resources has been able to turn around Medicare set-aside approvals within two weeks, said Jennifer Jordan, Columbia, Maryland-based general counsel of Medicare compliance company Medval L.L.C.

Moving to a new contractor likely would extend approval times since a new firm would have a learning curve on properly reviewing those accounts, sources said.

“No one bidding on this job will have experience in the legal aspects of all 50 states' workers compensation laws,” Ms. Jordan said in an email.

That could prompt some workers comp claim payers to forgo the reviews that often ask payers to save for medical treatments that are no longer offered to the injured worker or have been denied under reviews, she said.

“Those that get CMS approval typically receive higher MSA amounts than those who don't,” Ms. Jordan said. “When CMS approval is not available, payers tend to evaluate future medicals like they would when they reserve and it is (nowhere) near as high as a CMS-approved MSA.”

Still, Ms. Wilson believes workers comp claim payers should go through the process to ensure that they have CMS' backing when setting up Medicare set-asides.

“For those who seek justification for a position they've already taken regarding submission, this will provide further validation,” Ms. Wilson said. “For those who see the CMS review and approval as providing a degree of certainty in settling workers compensation claims, this will likely not be enough to entice a change in philosophy.”