INSIDER SECRETS: CMS Review and Approval of MSAs

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Recently, a client asked, “If I submit a Medicare Set Aside (MSA) to the Centers for Medicare and Medicaid Services (CMS) for review and approval, will it be approved?

True story: 

A few years ago, when the Workers Compensation Review Center (WCRC) was in Baltimore, MD, and CMS determinations were in a backlog for months, even up to a year; as the CEO of the largest MSA provider at that time, I took a trip and went in person to the WCRC with my complete list of pending MSA Reviews.   

I rang the doorbell to the office, there was no one at the reception desk. I knocked, rang a couple more times and when no one came to the door, I opened it and walked inside, and a blaring alarm sounded. 

The receptionist hurried to turn off the alarm. I introduced myself and explained the purpose of my visit. I had clients waiting months for CMS determinations and I wanted to discuss the list to get the outstanding MSAs resolved for my clients, the CMS determination delay was precluding their settlements.

The receptionist apologized for not being present to open the door for me and explained that he was reviewing MSAs. That is right. When the WCRC was short staffed, the receptionist (with no clinical, workers comp or MSA knowledge) would “review” MSAs.

Now, whenever I see a CMS MSA determination that defies logic, I reason it was reviewed by the receptionist!

Care Bridge International MSAs are reasonable and probable future care analysis, based on the machine learning of thousands of similar claims. Our data, methods and processes have been independently actuary reviewed and endorsed since 2017. Data Intelligence based MSAs are reproducible and statistically dependable. Care Bridge International MSAs demonstrate compliance with the Medicare Secondary Payer (MSP) statute without shifting the liability of non-group health claims to the Medicare Trust Fund. 

Regardless, proposed MSAs submitted to CMS for review and approval may or may be approved as proposed because WCRC reviews are subjective, not objective, and the WCRC does not follow traditional Medicare claims adjudication guidelines or acknowledge Workers Comp State Laws or Independent Medical Examinations (IMEs).

The CMS review process was dictated to CMS by the MSA industry itself, not CMS, the insurance or actuarial industry. In the absence of any proven method, Life Care Planning methods were shortcut and manipulated to create a use for Medicare Set Asides. The result is that diagnostic tests, used to “diagnosis” a medical condition, are allocated into the future for conditions already diagnosed! Unrealistic. Prescriptions drugs, which change and wean within the first 3 years post settlement, are allocated for the claimant’s entire life expectancy. Inaccurate. In addition, surgical procedures with a low statistical probability of occurring are included in an MSA. Pain management modalities and devices are grossly over-funded in MSAs. According to our research, MSAs are over-funded 30%, on average. This 30% difference is the profit margin for post settlement account administration companies, who have verified this over-payment, for the majority of MSAs.

Non-Submission of MSAs is a reasonable choice to protect the parties from CMS overreach. According to the WCMSA Reference Guide, “It is important to note, however, that CMS approval of a proposed WCMSA amount is not required.” and It is recommended; because CMS would like the MSA noted in the CMS Common Working File (CWF). While Non-Submit MSAs are invisible to CMS, as they are not recorded in the CMS Common Working File, they nevertheless show compliance with the MSP.

Some companies offer MSAs at an excessive cost, with the highest possible, not probable, future care projection under the guise of a “guarantee” program. These MSAs are grossly over-funded, the increased cost to falsely insure against a CMS Counter-higher determination. Claimants will not permanently exhaust these MSAs, and payers incur excessive costs for a false sense of security as these MSAs are not legitimately insured via an insurance policy.

Care Bridge International offers another choice, the Analytic-Powered Medicare Set Aside (APMSA). For most claims, our data intelligence platform can generate an MSA in minutes for non-submission. Paired with a post settlement support service, this MSA is proven to be accurate for protecting Medicare’s interests, and the parties to the claim, while avoiding unnecessary overpayments for future care or over-funded false guarantee programs. Using Care Bridge’s API and a data feed of claims data points, we can generate Non-Submit MSAs or Pre-MSAs at scale, overnight, at a significantly lower price point. Paired with a post settlement support administration and structured settlement, MSA funds are protected and properly exhausted in compliance with the MSP at a lower cost that reduces friction in the settlement process to facilitate successful settlements.

MSAs for CMS Review are produced by our clinical experts using data intelligence, and their knowledge of CMS review practices, for CMS Approval. A ClaimMAP is included with MSAs to detail opportunities for cost containment at no additional cost.


Seeking options for Medicare Set Asides? Tired of delays and excessive costs? Contact us now!

Don’t just take our word for it.

Quote: “We quickly reached a settlement agreement using the non-submit APMSA with post settlement account administration, and the Mediator was very impressed!” – Senior Adjuster, TPA

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