I'm headed to the NAMSAP conference this evening (National Association of Medicare Set-Aside Professionals), so I've been thinking about and talking about the MSA process with our customers quite a bit over the last few weeks. I'm not an expert in the field, but I have made a few observations that I hope are helpful. (Note: The Medicare Secondary Payer rules are mind boggling. I have a great deal of respect for those that deal with this process day in and day out.)
First, the MSA process is largely percieved as arbitrary (at best) and capricious (at worst). I know there are professionals that have a better read on CMS and can offer insight and manage expectations appropriately, but among the claims professionals I've been talking with, I hear frustration, disappointment, and genuine surprise regarding the CMS response to MSA submissions.
Second, as inefficient as the process is perceived to be, there are some clear areas of concern that are both apparent and potentially controllable by both the carrier and the injured worker. One of those areas happens to be the money spent on drugs.
I've heard countless stories of MSA calculations resulting in potential settlement amounts in the hundreds of thousands or millions of dollars, driven in large part by the medication regimen. A few thousand dollars a month worth of drugs... and a rated life expectancy of 20+ years... the numbers get big pretty quickly.
A few quick tips. These would fall under the category of "MSAs for Dummies," because I personally know a few people that could teach a semester-long class on this topic. But here are a few easy concepts for those new to MSAs or struggling with a particular case at the moment:
1) Don't settle a case until the MSA is approved by CMS. Some of you might bristle at this (who would do such a thing?) I've worked with payers on several cases recently where CMS came back with a revised MSA that was significantly higher than the settlement amount. This creates a multitude of issues, not the least of which will be a demand from plaintiff's counsel for the difference.
2) If you suspect the drugs are going to result in a large MSA calculation, don't conduct the calculation until you're certain the drugs are medically necessary and related to the work injury. If you suspect the drugs don't meet that criteria, clearly establish that fact before moving forward with the MSA. This isn't easy. In fact, it can take anywhere from 3 months to a year to do this right. For those that need additional guidance in this area, let me know.
3) If you've already had an MSA drafted and it's clear that due to the number, settlement isn't probable... see #2 above.
Rationalizing treatment before fully engaging in the MSA process is a great way to increase the probability of successful settlement for cases with high dollar drug spend.
On Twitter @PRIUM1