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Athens News

The Impact of Medicare on Workers’ Compensation Claims

A 2009 California Workers’ Compensation Institute study has found:

  • Claims with Medicare involvement are approximately 20% more costly than those without.
  • 6.5% of all permanent disability claims involved Medicare-eligible claimants.

What triggers Medicare’s involvement in a claim?

  • The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000.
  • The claimant has a “reasonable expectation” of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.

What does Medicare involvement mean to a claim? Usually, Medicare Set-Aside Arrangements

The Centers for Medicare/Medicaid Services (CMS) requires their interests be protected prior to any settlement of the medical portion of a claim for qualified individuals. The recommended method to protect Medicare’s interests is a Workers’ Compensation Medicare Set-aside Arrangement (WCMSA), which allocates a portion of the WC settlement for future medical expenses. The amount of the set aside is determined on a case-by-case basis and should be reviewed by CMS, when appropriate.

What determines the value of a Medicare Set-Aside (MSA)?

A case’s specific facts — such as type of injury, claiman’s age and life expectancy, and anticipated future medical costs — determine the MSA value of the MSA.

Medicare Getting Serious about Protecting their Interests… New Reporting Requirements

Effective January 1, 2011, insurers will be required to report substantial data to the CMS. Failure to report in the time and manner as specified by CMS carries a $1000 per day per claim civil penalty.

Athens Administrators’ approach to Complying with Medicare Reporting Requirements

Athens Administrators has partnered with Gould & Lamb to utilize their “OneSource” solution. It is one of the only fully-developed and integrated compliance solutions in the industry today.

Our approach is to utilize the Mandatory Insurer Reporting data to automatically identify claims with Medicare’s Secondary Payer exposure, protecting our customers from potential fines, penalties and litigation post-reporting to CMS.

Additional Resources for Information about Medicare Set-aside Requirements

http://www.cms.gov/WorkersCompAgencyServices/02_workersco-

mpensationoverview.asp#TopOfPage

https://www.ncci.com/Documents/AIS-2009-Medicare-Arrangements.pdf