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Strategies to Streamline the Medicare Set-Aside Review and Approval Process

Many times, securing Medicare’s approval of a Medicare Set-aside (MSA) is a major step in finalizing a Workers’ Compensation settlement agreement. Understandably, therefore, the desire is for the process to go as quickly and as smoothly as possible.

The main reasons the review process may be delayed is development requests from Medicare for additional information or documentation. There are a few simple ways to ensure that the submission process goes as smoothly as possible and, for the most part, they fall under the common theme of current documentation.

First, make sure the claimant’s medical records are as up-to-date as possible. Where the claimant is no longer treating the injury at issue, or is not treating under the claim, it is a good idea to obtain a release from the claimant allowing you to obtain records from current treating physicians.

Second, provide the claimant’s prescription history for the last two calendar years. If the claimant has not filled prescription medications under the claim, Medicare very frequently requires a personal pharmacy history from the claimant. As with medical records, it is helpful to be able to directly obtain information from the claimant’s personal pharmacy.

Third, ensure that we can prove to CMS the date on which the claims payment history was created. If payments have not been made on the claim in the six months preceding submission, Medicare will require proof that the claim payment information is current.

Lastly, endeavor to finalize MSA funding and administration decisions prior to submission. While changing funding or administration decisions does not slow down the initial approval process, changes after CMS approval is obtained may necessitate a request to CMS for a revised determination. This process sometimes requires additional documentation from claimant and/or claimant’s counsel.

We are happy to assist you with the MSA submission process! We work with our clients to reduce the likelihood that development requests are issued and to streamline the approval process.


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