Successful Zero MSA Submissions
Written by: Kristina Bonanno, Esq.
Submitting a zero-dollar Medicare Set-Aside (“Zero MSA”) proposal to the Centers for Medicare & Medicaid Services (“CMS”) has long caused employers and insurance carriers to wait with bated breath while CMS assessed whether it was appropriate for the claimant to not receive any funding for their claim-related, Medicare-covered future medical care. Fortunately, CMS has historically provided consistent approval of Zero MSA proposals in two scenarios: (1) when the workers’ compensation claim remains fully denied and the employer or carrier has not made any medical or indemnity payments, and (2) when the workers’ compensation claim remains fully accepted but the claimant has completed all injury-related treatment. Unfortunately, however, many employers and carriers know from personal experience that CMS applies stricter scrutiny when reviewing submitted Zero MSA proposals.
Recently, our firm has been made aware of instances where CMS has declined to approve a Zero MSA even in the above scenarios, which has caused some employers and carriers to question whether seeking CMS approval of a Zero MSA is still appropriate. CMS still grants approval of submitted Zero MSA proposals, and it is important for employers and carriers to recognize the importance of partnering with a knowledgeable firm that can anticipate the additional concerns and documentation CMS may request from reviewing a Zero MSA. For example, in cases where the claim is fully denied, carriers should anticipate having to provide medical records (even if the carrier did not pay for the claimant’s medical treatment), a full payment history run for the entire claim, and a statement from the carrier or their attorney confirming the denied conditions and breakdown of the settlement amount. An experienced firm will be able to review the complete file for any exposure issues and can help craft statements to address common CMS concerns and avoid excessive development letters on Zero MSA submissions. Here is a recent success story on a Zero MSA submission file:
A client submitted a Zero MSA referral to Sanderson Firm for a fully denied workers’ compensation claim with the ultimate goal of receiving CMS’ approval of the Zero MSA. Upon analyzing the full claim file, our team recognized that CMS may question the denied aspects of the claim due to the wording of certain records. Rather than risk CMS returning an unfavorable non-zero determination amount, our professional staff drafted a custom statement for the carrier to sign that comprehensively addressed the denied aspects of the claim and breakdown of the settlement amount. This statement, along with a thorough file review, allowed for all potential areas of concern related to the Zero MSA to be addressed in advance of submitting to CMS and which resulted in a quick turnaround time and approval of the Zero MSA by CMS when the file was submitted.
In cases where the injured worker has completed treatment, an experienced firm can also help review physician statements, court orders, and medical records to make sure the documents on the claim are consistent and to help carriers address possible areas of exposure with CMS. For claims where treatment has concluded, a physician statement should be obtained to certify that no future treatment is being recommended. If there were any questions surrounding causation, these should try to be resolved with the treating physician or court as soon as possible so that there is consistency in the records instead of questions. If the estimated settlement amount is significantly above the threshold for CMS submission, workers’ compensation payers should be prepared to provide a breakdown of the settlement amount to show CMS that no portion of the settlement is being allocated for future medical care and the parties are not attempting to maximize the other aspects of the settlement (e.g., the lost wages and disability portions of the settlement) to Medicare’s detriment.
Partnering with an experienced firm like Sanderson Firm to address the additional concerns that come with the submission of a zero MSA before submitting to CMS allows for the best chance of a quick approval of a zero MSA. If you have questions regarding Zero MSAs or if you would like to engage Sanderson Firm for our MSA services, please contact us.
