Analytic-Powered Medicare Set Asides:

Read Time:4 Minute, 40 Second

Using the POWER of DATA for Accuracy in Compliance

Are you frustrated with Medicare Set Aside results?   Do MSAs often preclude settlement?

We randomly polled carriers, third party administrators, self- insured employers, and state / mutual funds in 2016 and out of 36 respondents, 100% of those polled stated Medicare Set Asides did in fact preclude settlements.   Since 2016, that sentiment has not changed.

We got to work to remove the friction in Medicare Set Asides as much as possible to help our clients settle claims while remaining in compliance with the Medicare Secondary Payer Statute.  Since 2016 Care Bridge International offers the only “Data Driven” Medicare Set Aside (MSA) in the marketplace. 

Our Analytic-Powered Medicare Set Aside© uses machine learning technology based on a database of the life cycles of over 16 million injury claims, and over a billion medical transactions.  In addition, evidence based clinical guidelines, the rules of CMS for Medicare Set Asides and the appropriate Fee Schedules for Workers Compensation and Liability (general or auto) claims are used, to accurately forecast medical treatment and costs for an individual claim.  Care Bridge International’s medical forecasting technology is the only Actuary reviewed and endorsed solution in the industry. No other service provider has proven measures of accuracy for their results.

Why use a Data Driven, Analytic-Powered Medicare Set Aside?

1.    Traditional Medicare Set Asides are over-funded 30%-40%

In our 2018 white paper, “What is the True Cost of Future Medical Care” we explain our research on the actual costs associated with future medical and the results may surprise you.

Professional Medicare Set Aside Administration companies validate that the average MSA is over-funded 30% or more.

2.    Claims involving Class 3 Medicare Beneficiaries need to consider Medicare’s interests too

Under the Medicare Secondary Payer Statute, CMS requires that “whenever future medicals are closed” in a Non-Group Health Plan (NGHP) settlement, that Medicare’s future interests must be considered.   That does not mean, however, that every MSA will be reviewed by CMS.   CMS has established a threshold for review in an effort not to overwhelm the system and manage its resources, so CMs will only review MSAs involving Class 1 and Class 2 Medicare Beneficiaries.

Our QUICK REFERENCE GUIDE , which you can download now,  explains which MSAs that CMS will review.  Since CMS will not review a Class 3 Medicare Beneficiary, the Analytic-Powered MSA is a fast, easy, inexpensive approach to complying with the consideration of future medical, based on the defensible power of data!

3.    Liability Medicare Set Asides (LMSA)

Liability Medicare Set Asides are nuanced in that most claims are settled for a nuisance value, meaning it is less costly to settle a claim for a smaller sum of money than to litigate it.  Liability claims do not involve medical management or provider networks as the plaintiffs may treat with whomever they wish up to a policy limit.  Primary Payers are unaware of the medical expenditures until the time of settlement and therefore medical information involving these claims is limited.   A traditional MSA service provider will require medical records which are not available to these primary payers and hence they are unable to service them expeditiously.  

With Care Bridge International, we can forecast medical treatment and costs with limited medical information, requiring only certain available claim data points to predict fast and accurate Liability Medicare Set Asides (LMSAs).

4.    Non-Submit Medicare Set Asides

As the use of non-submit Medicare Set Asides has accelerated in the past ten years, mostly due to the magnitude of friction in submitting MSA to CMS, more primary payers are opting out of submitting MSA to CMS for review and approval and instead using independent vendors to consider Medicare’s future interests, documenting the MSA as the portion of the medical settlement and closing claims without CMS Submission.  While the option to submit to CMS is “voluntary”, without a formal review, Medicare is unaware of these MSAs and unable to record them in the CMS common working file and it prefers submission.  However, as options to consider Medicare’s interests are needed to settle claims, primary payers are buying heavily allocated Medicare Set Asides, over-funding settlements with incurred over-payments. 

The submitted Medicare Set Aside is a “cookie-cutter” inclusive of excessive diagnostic tests, office visits, prescription medication, and surgeries to the extent that most service vendors no longer use licensed registered nurses with Medicare Set Aside credentials. Medicare Set Asides have become an entry level cost center with high profit margins and the primary payer is stuck with the over-payment.  For eligible claims, you will receive a defensible, high-quality report using an Analytic-Powered Medicare Set Aside.

At Care Bridge International, when submitting an MSA to CMS for review and approval, we believe clinical expertise should always be part of the Medicare Set Aside process, particularly for complex and catastrophic claims, and our approach may explain why our Medicare Set Asides are approved by CMS at 15% less than the industry average. 

Why Settle for Less?

For more information about Care Bridge International visit our Website

To request a sample Analytic-Powered Medicare Set Aside, simply email and enter APMSA in the Subject Line.

Call Toll Free 888-434-9326

Care Bridge International advanced its innovative technology platform in 2022, so stay tuned for exciting announcements in the New Year!