Stale Claims? No Problem!


As the end of the year draws near, we know that closing stale claims can become a priority. Whether it is a case with a previously-approved MSA that came back too high, a case with wildly high monthly medical costs, or even a case with a hesitant claimant, we may be able to help get your case across the finish line!


As we previously discussed here, Medicare provides an option for obtaining a revised determination when the previously-approved MSA is between one and six years old and there would be a difference of at least ten percent or $10,000.00 (whichever is greater) in the MSA amount. While the Amended Review option is an invaluable resource for cases in which the previously-approved MSA no longer meets the current settlement parameters or reflects current treatment, what about cases with previously-approved MSAs that everyone is still happy with? In those cases, no matter the length of time that has passed, the previously-approved MSA can simply be funded- no revision necessary! Importantly, however, the MSA would still need to be funded in the amount and according to the terms approved by CMS, despite the passage of time. As recently confirmed by CMS’ own John Jenkins, it is not acceptable to deduct portions of the MSA due to the passage of time. Value changes in the MSA would need to be addressed through the Amended Review process.


While there is a pretty clear path in cases with previously-approved MSAs, what about those cases in which the prior MSA allocation report came back too high to even consider submission? Of course, preparing a revised allocation report is the best way to determine the current MSA value. In cases where the monthly medical expenses remain high, we understand that you may be hesitant to pursue a revised allocation report, however, don’t let high medical costs scare you from evaluating current MSA values. There is still a chance that the cost of the MSA may have decreased since the last report was completed. This could be due to the cost of prescription medications decreasing, as has been the case for several common medications in recent years, the availability of a generic medication form, as is the case for Lyrica, the reduction of a claimant’s life expectancy by increased rated age, or even the removal of a required revision surgery. All of these things can work independently or as a whole to reduce the cost of Medicare Set-asides.


What if the holdup isn’t necessarily the cost of the set-aside, but a hesitant claimant who does not want to take control of managing their own medical treatment and related financials? If self-administration is too intimidating, professional administration is an excellent tool that can be utilized to take on the added responsibility of paying bills, maintaining funds, and providing annual accounting to Medicare. Even better, professional administration provides extra reassurance to the insurer/insured that the funds are being managed properly!


Finally, what about those cases that have gone stale because the claimant is treating out of network and you don’t have any idea of recent treatment or the cost of the same? Researching Medicare conditional payment claims and Medicare Advantage Plan liens can be a very useful tool to help determine what and where the claimant is treating.


No matter what the holdup might be, evaluating the current cost of medicals is a wonderful step toward closure of old claims that have been hanging around too long. If you would like assistance with evaluating the current cost of medicals in your old claims, please reach out! We are happy to help!



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