Medicare Secondary Payer Compliance (MSPC)

Balancing Medicare Secondary Payer Compliance and our client’s actual medical exposure on their claims

CareWorks’ has mastered the art of balancing Medicare Secondary Payer Compliance and our clients’ actual medical exposure on a claim. Unlike many companies that delay consideration of Medicare’s interest until claim closure when a decision must be made quickly, CareWorks begins analyzing claim information much earlier in the process. This “life of the claim” approach coupled with our cutting edge technology allows us to identify claims with potential Medicare beneficiaries early. We then consult with our client, the adjuster and Medicare to fully understand all parties’ view of the claim. 

Our Strategy

Our strategy affords us the ability to analyze the claim for any elements related to Medicare compliance and bring clarity to our clients’ responsibility for same. At the time of  settlement, we can ensure both compliance and that our client does not reimburse Medicare for more than is actually owed. On average, CareWorks is able to reduce our client’s Conditional Payment Medicare Reimbursements by 80%.

CareWorks’ team includes registered nurses with MSCC and CMSP certifications who thoroughly understand not only Medicare Set Aside analysis but how to manage claims with Medicare components. Couple that with our full spectrum of services and you have a solution that supports cost containment while maintaining Medicare Secondary Payer (MSP) compliance.

Client Education

CareWorks is your solution for education on sound and reasonable Medicare Secondary Payer compliance. We provide complimentary webinars or onsite training for clients and adjusters to ensure that all parties involved in Medicare Secondary Payer Compliance have a thorough, working knowledge of what is involved, what their role is, and how, as a team, we can achieve the best results for the client.

Ancillary Services

CareWorks’ Medicare Secondary Payer Compliance also offers the following services to our clients:

  • Social Security Disability Eligibility Verifications
  • Medicare Eligibility Verifications
  • Rated Age Evaluations
  • Conditional Payment Services
  • Professional Administration Coordination
  • Structured Settlement Coordination
  • Final Settlement Document Coordination/Submission
What We Offer:
  • Sector 111 Reporting
  • Conditional Payment Services
  • Medical Allocation Services

To ensure that our clients are in compliance with the complex and sometimes cumbersome Section 111 requirements, we have developed a seamless Section 111 Reporting process.

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) defines the reporting requirements that will give Medicare the data it needs to enforce compliance with the Medicare Secondary Payer (MSP) statute, which  requires that Medicare not pay for medical treatment when another primary payer – such as an insurer or self insurer is available.

Our state-of-the-art technology incorporates sophisticated cross checks that identify data quality errors before final claim reports are submitted.

When an injured individual is a Medicare beneficiary, there is the potential that Medicare has made medical payments related to the claim. Any past payments made by Medicare upon the condition that they would be reimbursed at the time of settlement, judgment, or award must be taken into consideration when determining the final settlement.

Our team of professionals has the tools to achieve successful and significant Medicare Reimbursement Resolutions. We carefully assess the conditional payment status of a Medicare beneficiary and work closely with the Medicare Secondary Payer Recovery Contractors (MSPRC) to obtain lien information and submit effective conditional payment resolution proposals.

Our proactive approach to conditional payments ensures that Medicare’s interest is taken into account but also that there are no payments reimbursed that were not part of the claim. The CareWorks Conditional Payment Program has served our clients well; as evidenced by reduction in conditional payments by as much as 92%.

CareWorks offers a comprehensive suite of Medical Allocation Services to meet the strategic objectives of client partners throughout the claim lifecycle. From setting reserves to discussing a life care plan, CareWorks has mastered the art of balancing compliance with our clients' actual medical exposure.

Medicare Set-Aside Arrangement
The MSA arrangement is a compilation of the medical records and future payment projections over the life expectancy (or appropriate time frame) of the injured or ill individual. CareWorks will obtain a rated age to identify a true life expectancy which may significantly and appropriately reduce the allocation, ultimately allowing more opportunity to reach final settlement agreements. Our average turn around time for standard MSA is 10 business days, CareWorks is flexible in our service offerings. We offer a Rush MSAs service (where an MSA is needed within 1-5 days), and provide MSA Updates on those products we originally completed, as well as the standard MSA.

Medicare Set-Aside Submissions to CMS
CareWorks manages the MSA submission for our clients. Our team members proactively monitor submissions to ensure there are no unforeseen delays and that we deliver efficient turnaround times on CMS approvals. The average CMS acceptance rate for CareWorks’s MSA allocations being “approved as submitted” is 85%. We are committed to assisting our client partners through life of claim and beyond. Upon completion of settlement we will coordinate the final settlement document submission to CMS to ensure a comprehensive compliance approach.

MedicalCost Projection
The Medical Cost Projection product summarizes medical records and apportions Medicare and non-Medicare future medical expenses throughout the life expectancy of the ill or injured worker and is used as a strategic tool in reserve-setting or settlement development. CareWorks’s experienced professionals can deliver an appropriate future medical projection for cases where our clients determine an MSA is not the appropriate strategy. In addition, CareWorks can convert a Medicare Cost Projection to a Medicare Set Aside Allocation when warranted.

Life Care Plan
A Life Care Plan is prepared when a claim involves a catastrophic injury. This product is a comprehensive development of all the medically-related services required by an individual for the remainder of their lives. CareWorks offers certified Life Care Planners who research each claim in detail, perform comprehensive data analysis and provide thorough documentation to deliver a quality Plan for future medical needs. The Life Care Plan is considered a living document and may be amended over time.

A truly effective managed care solution

Our comprehensive array of managed care services deliver the right results for our clients and their injured workers.

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