When parties choose to avail themselves of the CMS Workers’ Compensation Medicare Set-Aside (WCMSA) voluntary submission process and the claimant is left to self-administer the WCMSA funds, there is “happily ever after” assumption that follows. The parties sometimes assume the case will be closed forever; claimant will be able to properly administer the funds; and CMS will never deny treatment or assert a recovery right; however, this is not always the case. Let’s take a closer look at this with the example below.
Claimant, John Smith, is Medicare eligible. The parties are resolving his workers’ compensation claim with a lump sum payment of $70,000 plus the cost of the WCMSA. The parties have chosen to avail themselves of the CMS Workers’ Compensation Medicare Set-Aside (WCMSA) voluntary submission process. The WCMSA was tentatively approved at $120,000 and the parties proceed to settle the claim with John to self-administer the WCMSA funds. John has been on workers’ compensation benefits for ten (10) years and has relied on the claims professional assigned to his claim to manage all his medical and prescription bills. He was reluctant to settle because he did not want to “go it alone,” but ultimately did agree to go forward. He sees multiple doctors for both work-related and non-work-related conditions and is treating in a workers’ compensation fee schedule state.
When self-administering his WCMSA, John unintentionally pays for bills related to his other conditions and for treatment that is not Medicare covered. He does not understand how to obtain fee schedule pricing from his providers and his WCMSA has exhausted ten (10) years prior to the end of his suggested life expectancy. Medicare is now denying payment for both pre-existing and work-related conditions. John is on the phone now daily with CMS, his prior claim’s adjuster and his attorney to try and get answers on just what went wrong.
The example above is, unfortunately, not uncommon. Self-administering a WCMSA can not only be time intensive, but also confusing. CMS does provide a Toolkit to assist in this effort, but claimants are ultimately responsible for managing the day to day operations of the WCMSA account. This is something they were never required to do before. Claimants are also having to negotiate pricing and treatment options with providers and in many circumstances can exhaust the WCMSA prematurely opening them up to Medicare co-pays and potential denials of treatment. In addition, these issues may impact all the parties down the line when claimant turns to the claims adjuster or counsel for answers.
Self-administration of the WCMSA by the claimant whether the WCMSA is submitted to CMS for voluntary approval or through a non-submit option is extremely common and often preferred by claimants and their counsel. Balancing claimants’ need to administer the WCMSA funds with additional support to do so properly and effectively is what self-administration support services should provide. Never directing care or controlling the WCMSA monies, self-administration support is meant to be a tool, resource and touch pointe for the claimant to help obtain fee schedule pricing, pharmacy and DME discounts, bill reviews, and other essential resources to help prevent the premature exhaustion of the WCMSA and the unintentional mismanagement of funds. It also serves as a resource for the claimant to reach out to with questions on Medicare denials or coverage questions. Self-administration support services are also an extremely important tool when settling with unrepresented claimants or claimants like John above that may be reluctant to settle because they do not want to “go it alone.”
At NuQuest, Self-Administration Support Services are offered in conjunction with our NuShield Certified MSAs and we also offer Self-Administration Support Services in addition to our WCMSA submission process through our Bridge Pointe team.
For further information on our Self-Administration Support options, please contact Kasey Haggerty, VP of Business Development-Bridge Pointe. Kasey develops, coordinates and implements plans that are designed to increase existing business as well as capture new opportunities. He brings over a decade of experience in the workers compensation insurance industry and a wealth of experience and focus to helping customers make their medical settlement dollars go further.
He chooses to work for an organization where he believes in the product and that it provides a valued service to those in need. “Seeing our clients maintain their financial security after an injury makes me incredibly proud of what we do.”
Email: [email protected]
Phone: 877.551.3900 ext. 4897