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September 10, 2025

A Medical Paralegal Services Evaluation will:

• Identify and value future medical care requirements, including that which may be disputed or need further workup

• Identify Medicare and non-Medicare covered medical expenses and provide proper allocations

• Assist you in documenting that the interests of your client and Medicare have been considered on cases where an MSA will not be submitted

• Offer medical evidence to support your position, based on state and Medicare guidelines

• Enhance your understanding of the medical strengths and weaknesses of your case

• Assist you in understanding the difference between the Applicant/Defense cost projections

• Save you and your staff time

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September 3, 2025

Did you know?  A Medical Paralegal Services Future Medical Exposure Evaluation is more than just a cost projection. It is a powerful tool that can assist you and your clients in a number of ways.

Our reports are often used on smaller cases to set a reasonable foundation for settlement negotiations and client expectation management.

Check out this recent example…

FACTS:

• Straightforward lumbar injury case, status post fusion.  Applicant at MMI, doing well, and back to work. No dispute regarding compensability, indemnity, or denied medical care

• Very limited future medical care was recommended by physician

• The Applicant insisted they wouldn’t settle for less than $500k on the future medical side because their friend had similar issues and got more than that

• Carrier offered 70k for future medical

• MSS valued future medical exposure at $115,000.00

RESULT:

Our client was able to educate the Applicant as to the reasonable value of the future medical claim with information supported by the medical record.   The Applicant’s expectations were reset.  Our client was able to confidently make a reasonable and supportable demand that resulted in an additional 15k at settlement!

A fantastic use of our report and a fantastic outcome for our client and the Applicant!

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August 19, 2025

What do we deliver?

• Strategic Future Medical Valuations on cases of all sizes for use during case planning and settlement negotiations regardless of Medicare involvement

• Valuations supported by Medicare and/or state guidelines

• Support during settlement proceedings/mediation

• Bulk settlement capability (multiple cases with same carrier/defense – “Settlement Days”)

• Alliances with other consultants to offer a wide range of settlement options for structuring and custodial account management

• Peace of mind – our services provide information that contributes to your ability to know the medical facts of your case, educate your clients accordingly, and document the responsibility and care exercised in assessing the medical value of the claim

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August 15, 2025

Conditional Payment Notifications

MSA Reporting Series Part VII

If CMS believes conditional payments exist, a Conditional Payment Notification (CPN) will be issued.  

If Medicare is pursuing recovery directly from the insurer/workers’ compensation entity, the beneficiary and beneficiary’s attorney or other representative will receive a copy of recovery correspondence sent to the insurer/workers’ compensation entity. The beneficiary does not need to take any action on this correspondence. However, if Medicare is pursuing recovery from the beneficiary, the BCRC will send recovery correspondence to the beneficiary.  

A conditional payment letter (CPL) provides information on items or services that Medicare paid conditionally and the BCRC has identified as being related to the pending claim.

During its review process, if the BCRC identifies additional payments that are related to the case, they will be included in a recalculated Conditional Payment Amount and updated CPL. If CMS determines that the documentation provided at the time of the dispute is not sufficient, the dispute will be denied. You and your attorney or other representative will receive a letter explaining Medicare’s determination once the review is complete.

The BCRC will apply a termination date (generally the date of settlement, judgment, award, or other payment) to the case. The BCRC will identify any new, related claims that have been paid since the last time the CPL was issued up to and including the settlement/judgment/award date. Once this process is complete, the BCRC will issue a formal recovery demand letter advising of the conditional payment amount of money owed to the Medicare program. The amount of money owed is called the demand amount.

If the beneficiary, their attorney or other claim representative believe that any claims included on CPL/PSF or CPN should be removed from Medicare's interim conditional payment amount, documentation supporting that position must be sent to the BCRC. This process can be handled via mail, fax, or the MSPRP. The BCRC will adjust the conditional payment amount to account for any claims it agrees are not related to the case.

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

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July 28, 2025

Settling a case before CMS approves a submitted MSA

MSA Reporting Series Part VI

Did you know you can settle a case before CMS reviews/approves the MSA?  However, even if CMS approves the MSA, the approval is not effective until they receive specific settlement information – Read on to learn more!

Per CMS guidelines, the parties can proceed with the settlement of the medical expenses portion of a WC claim before CMS actually reviews the proposed WCMSA and determines an amount that adequately protects Medicare's interests. However, approval of the WCMSA is not effective until a copy of the final executed WC settlement agreement, which must include the funding information for the WCMSA amount, is received by CMS.

No statement in the settlement of the amount needed to fund the WCMSA is binding on CMS unless and until the parties provide CMS with documentation that the WCMSA has actually been funded for the full amount that adequately protects Medicare's interests as specified by CMS as a result of its review. Include only official documents, such as WC petitions, mediation documents, prior awards and settlements, court orders, draft and final settlement agreements, and annuity rate sheets.

If CMS does not subsequently provide approval of the funded WCMSA amount as specified in the settlement or proof is not provided to CMS that the CMS-approved amount has been fully funded, CMS may deny payment for services related to the WC claim up to the full amount of the settlement. Only the approval of the WCMSA by CMS and the submission of proof that the WCMSA was funded with the approved amount, would limit the denial of related claims to the amount in the WCMSA. This shall be demonstrated by submitting a copy of the final, signed settlement documents indicating the WCMSA is the same amount as that recommended by CMS.

The claimant may be at risk if the WCMSA is funded for less than the amount that CMS determines to be adequate to protect Medicare's interests.

PLEASE NOTE: If the settlement does not specifically account for past versus future medical expenses, it will be considered to be entirely for future medical expenses once Medicare has recovered any conditional payments it made. This means that Medicare will not pay for medical expenses that are otherwise reimbursable under Medicare and are related to the WC case, until the entire settlement is exhausted.

• Example: A beneficiary is paid $50,000 by a WC carrier, and the parties to the settlement do not specify what the $50,000 is intended to pay for. If there is no CMS-approved WCMSA, Medicare will consider any amount remaining after recovery of its conditional payments as compensation for future medical expenses.

Additionally, please note that any allocations made for lost wages, pre-settlement medical expenses, future medical expenses, or any other settlement designations that do not consider Medicare's interests, will not be approved by Medicare.

• Example: The parties to a settlement may attempt to maximize the amount of disability/lost wages paid under WC by releasing the WC carrier from liability for medical expenses. If the facts show that this particular condition is work-related and requires continued treatment, Medicare will not pay for medical services related to the WC injury/illness until the entire settlement has been used to pay for those services.

What does CMS consider the total settlement amount?  The computation of the total settlement amount includes, but is not limited to, an allocation for future prescription medications of the type normally covered by Medicare, in addition to allocations for other Medicare covered and non-covered medical expenses, indemnity (lost wages), attorney fees, set-aside amount, non-Medicare medical costs, payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), amounts forgiven by the carrier, prior settlements of the same claim, and liability settlement amounts on the same WC claim (unless apportioned by a court on the merits).

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

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July 18, 2025

What Happens When A Claim Is Reported After A Case Is Settled or Conditional Payments are made?

MSA Reporting Series Part V

The Benefits Coordination & Recovery Center (BCRC) is responsible for recovering conditional payments made during the course of a workers’ compensation claim when there is a settlement, judgment, award, or other payment made to the Medicare beneficiary.  The Parties, including Beneficiaries and their attorney(s) should recognize the obligation to reimburse Medicare during any settlement negotiations, and determine who will be responsible for paying conditional payments, if any.

When there is a settlement, judgment, award, or other payment, the beneficiary, their attorney, carrier, or other representative should notify the BCRC.   The BCRC process may also be (and is often) triggered when an MSA is submitted, approved, and the final settlement documents are received by CMS.

However, if there is an outstanding conditional payment at the time of settlement that is not addressed in the settlement, the beneficiary may be in for a big surprise.

If CMS believes conditional payments exist,  and a settlement, judgment, award, or other payment has already occurred when a case is first reported, a Conditional Payment Notification (CPN) will be issued.  A CPN will also be issued when the BCRC is notified of settlement, judgment, award, or other payment through an insurer/workers’ compensation entity’s MMSEA Section 111 report. The CPN provides conditional payment information and advises on what actions must be taken.

How can an Applicant be proactive regarding conditional payments?  

• Make sure CMS is notified as soon as there is a pending liability, no-fault, or workers’ compensation claim

• Parties may obtain a current conditional payment amount periodically throughout the claim to stay on top of any issues

• Obtain current conditional payment information at the time of settlement

• Clearly identify body parts admitted under claim in the settlement documents. If needed, a statement that all other body parts/claims are denied. Please consider jurisdictional requirements regarding settlement language.

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.  

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July 10, 2025

What Happens When a Workers’ Compensation Claim for a Medicare Beneficiary is Reported to CMS?

MSA Reporting Series Part IV

As noted earlier in our series, the purpose of reporting such claims to CMS is so that CMS can assure Medicare remains the secondary payer for medical care related to the claim, and recover any applicable conditional payments.  

Once the case has been reported, the BCRC will collect information from multiple sources to research the MSP situation, as appropriate (e.g., information is collected from claims processors, Medicare, Medicaid, and SCHIP Extension Act (MMSEA Section) 111 Mandatory Insurer Reporting submissions, and workers’ compensation entities).

If the BCRC determines that the other insurance is primary to Medicare, they will create an MSP occurrence and post it to the Medicare records. If the MSP occurrence is related to an NGHP, the BCRC uses that information as well as information from CMS’ systems to identify and recover Medicare payments that should have been paid by another entity as primary payer.

After the MSP occurrence is posted, the BCRC will send the beneficiary a Rights and Responsibilities (RAR) letter. The RAR letter explains what information is needed from the beneficiary and what information can be expected from the BCRC. Please note: If Medicare is pursuing recovery directly from the insurer/workers’ compensation entity, the beneficiary and their attorney or other representative will receive recovery correspondence sent to the insurer/workers’ compensation entity.

The BCRC then begins identifying claims that Medicare has paid conditionally that are related to the case, based upon details about the type of incident, illness or injury alleged. Medicare's recovery case runs from the “date of incident” through the date of settlement/judgment/award (where an “incident” involves exposure to or ingestion of a substance over time, the date of incident is the date of first exposure/ingestion).

Within 65 days of the issuance of the RAR Letter, the BCRC will send the Conditional Payment Letter (CPL) and Payment Summary Form (PSF). The PSF lists all items or services that Medicare has paid conditionally, which the BCRC has identified as being related to the pending case.

The CPL explains how to dispute any unrelated claims and includes the BCRC’s best estimate, as of the date the letter is issued, of the amount Medicare should be reimbursed (i.e., the interim total conditional payment amount). The conditional payment amount is considered an interim amount because Medicare may make additional payments while the case is pending. If there is a significant delay between the initial notification to the BCRC and the settlement/judgment/award, the beneficiary, attorney or other representative may request an “interim conditional payment letter” which lists the claims paid to date that are related to the case.

The current conditional payment amount can be obtained from the BCRC or the Medicare Secondary Payer Recovery Portal (MSPRP). To obtain conditional payment information from the BCRC, call 1-855-798-2627.

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

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July 1, 2025

Conditional Payments

MSA Reporting Series Part III

The Medicare Secondary Payer (MSP) provisions make Medicare a secondary payer to certain non-group health plans (NGHPs), which include workers’ compensation entities, liability insurers (including self-insured entities), and no-fault insurers.  CMS has the right to recover Medicare payments made that should have been the responsibility of an NGHP or another payer.

MSP situations involving NGHPs are typically triggered by unexpected incidents, such as car accidents or work-related injuries involving Medicare beneficiaries, and result in medical expenses for which an NGHP has primary responsibility for payment, instead of Medicare. In these situations, Medicare becomes a secondary payer.

In some MSP situations involving NGHPs, Medicare will initially pay for related medical expenses in order to ensure that the beneficiary has timely access to needed care and later seek to recover those payments. These are known as “Conditional Payments.” A conditional payment is a payment Medicare makes for services another payer may be responsible for. The payment is "conditional" because it must be repaid to Medicare when a beneficiary receives a settlement, judgment, award, or other payment from an NGHP.

Other common situations in a workers’ compensation claim that may result in conditional payments for a Medicare Beneficiary include (but are not limited to):

• Bills for services related to treatment for the industrial injuries are inadvertently sent to Medicare either by the treater or patient (Medicare beneficiary)

• Items and services are denied; the patient submits the bills to Medicare and the services or items are eventually accepted under the claim

• The patient goes to a provider for a service not related to the claim, but claim related issues are discussed or treated in the same visit and on the same record (more common with providers such as Kaiser)

The Benefits Coordination & Recovery Center (BCRC) is responsible for ensuring that Medicare gets repaid by the beneficiary for any conditional payments it makes related to a liability, no-fault, or workers’ compensation case for parts A and B claims. When the BCRC learns of an NGHP case, they will gather information about any related conditional payments Medicare made and request repayment.

Please note that recovery for parts C (Medicare Advantage Plan) and D (Optional Prescription Drug Plan) claims are the responsibility of the issuing plan and separate inquiries may be required.

It is important to understand any outstanding conditional payment amounts prior to settlement, so that the exposure for those payments can be considered by the carrier when setting reserves for settlement funding.  Otherwise, the Applicant/Beneficiary may receive an unexpected bill for any owed conditional payments post settlement.

To obtain a conditional payment information, interested parties may contact BCRC Customer Service Representatives Monday through Friday, from 8:00 a.m. to8:00 p.m., Eastern Time, except holidays, at toll-free lines: 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for the hearing and speech impaired).

Note that Medicare does not release information from a beneficiary’s records without appropriate authorization. If the beneficiary has an attorney or other representative, he or she must send the BCRC documentation that authorizes them to release information.  The attorney or other representative will receive a copy of the RAR letter and other letters from the BCRC as long as he or she has submitted a Consent to Release form.

A Consent to Release (CTR) authorizes an individual or entity to receive certain information from the BCRC for a limited period of time. With that form on file, the attorney or other representative will also be sent a copy of the Conditional Payment Letter (CPL) and demand letter. If the attorney or other representative wants to enter into additional discussions with any of Medicare’s entities, a Proof of Representation document will also need to be submitted. A Proof of Representation (POR) authorizes an individual or entity (including an attorney) to act on your behalf.  It is in the best interest of both sides to have the most accurate information available regarding the amount owed to the BCRC prior to settlement.

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.

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June 24, 2025

Reporting A Workers’ Compensation Claim to CMS

MSA Reporting Series Part II

The Benefits Coordination & Recovery Center (BCRC) is responsible for ensuring that Medicare gets repaid by the beneficiary for any conditional payments.

If an injured worker has Medicare and other insurance coverage, each type of coverage is called a “payer.”  When there’s more than one potential payer,there are coordination rules to decide who pays first.

Medicare may pay secondary to no-fault insurance, liability insurance or workers’ compensation. To ensure correct payment of Medicare claims, CMS advises Medicare Beneficiaries to always contact the BCRC first whenever they have a pending Liability, No-Fault, or Workers’ Compensation case.  According to CMS, this obligation is fulfilled by reporting the case in the Medicare Secondary Pay or Recovery Portal (MSPRP) or by contacting the Benefits Coordination & Recovery Center (BCRC).

Often in workers’ compensation claims however, CMS is first notified that a Medicare Beneficiary has a workers’ compensation claim when the claim is reported via Section 111 reporting via the Responsible Reporting Entity (RRE)as noted in Part I of our series and/or when an MSA is submitted to CMS for review.

Once the case has been reported, the BCRC will collect information from multiple sources to research the MSP situation, as appropriate (e.g.,information is collected from claims processors, Medicare, Medicaid, and SCHIP Extension Act (MMSEA Section) 111 Mandatory Insurer Reporting submissions, and worker’s compensation entities).

Beneficiaries can access the MSPRP through the Medicare.Gov Website using their established Login ID and Password for that site. The Website can be accessed from the link: www.Medicare.gov.

Insurers and attorneys will access the MSPRP using the MSPRP Application link:https://www.cob.cms.hhs.gov/MSPRP/. Please note that registration must occur before access to the MSPRP is permitted.

Once notified, the BCRC will begin identifying claims that Medicare has paid conditionally that are related to the case, based upon details about the type of incident, illness or injury alleged. Medicare's recovery case runs from the“date of incident” through the date of settlement/ judgment/ award (where an“incident” involves exposure to or ingestion of a substance over time, the date of incident is the date of first exposure/ingestion).

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.  

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June 19, 2025

New Medicare Reporting Rules

MSA Reporting Series Part I

CMS stands for the Centers for Medicare & Medicaid Services.  In relationship to a workers’ compensation claim, CMS is responsible for protecting the Medicare program's fiscal integrity and ensuring that it pays only for those services that are its responsibility.

CMS captures Medicare Set-Aside (MSA) information via the Section 111 reporting process of the Medicare, Medicaid, and SCHIP Extension Act for workers’ compensation settlements.  

It is currently the position of CMS that while it might be possible to tie a voluntary Workers’ Compensation Medicare Set-Aside (WCMSA) submission to a Total Payment Obligation to Claimant (TPOC) report based on the beneficiary information and Date of Incident (DOI), CMS cannot guarantee that the parties are using the voluntary WCMSA amounts, as parties may have decided to use an Evidence-Based MSA, another type of unsubmitted MSA, or otherwise settled future medical where a case does not meet review thresholds.

Therefore, effective April 4, 2025, CMS started mandating Section 111 reporting of WCMSA data for all settlements (including those with zero dollar allocations) involving injured workers who are, or were Medicare beneficiaries.This includes any settlements below the CMS review threshold of$25,000.00.

In general, the Responsible Reporting Entities (RRE) who must report per Section 111 are self-insured employers, liability insurers, compensation insurers and third-party administrators. This reporting is mandatory, regardless of whether the WCMSA is approved by CMS or not.

Per CMS: Failure of an RRE to comply with its reporting obligations may result in CMS utilizing all available statutory and regulatory options to recover mistakenly made payments, including bringing an action against the RRE under the False Claims Act.

Section 111 reporting is not a replacement for submission of settlement documents which is still required by CMS to finalize the WCMSA approval process.  CMS review remains voluntary and the review thresholds are unchanged.

Despite the fact that not all cases involving future medical settlements are eligible for CMS review, CMS review and approval is the only process that offers both Medicare beneficiaries and defendants finality.  When CMS approves a proposed WCMSA amount, CMS will stand behind that amount. Without CMS’s approval, Medicare may deny related medical claims, or pursue recovery for related medical claims that Medicare paid up to the full amount of the settlement, judgment, award, or other payment.

Not all cases are “eligible” for an opportunity to be approved by CMS, yet all settlements consider Medicare’s interests.  Therefore, it is more important than ever to have an accurate understanding of future medical exposure in all cases involving future medical settlements.

Do you have questions about MSAs, how to value future medical care or positioning your cases for future medical settlement?    Contact us formore information!

Note:  The information contained herein was obtained from CMS and Medicare Secondary Payer resources and is not to be considered legal advice.  

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April 18, 2025

Frequent Reasons Why the CMS MSA Reviewer Requests Additional Information to be Submitted

• Insufficient or out-of-date medical records (Medical records from the most recent 2 years of treatment should be submitted, regardless of who paid for treatment)

• Insufficient or out-of-date payment histories (Payment histories should be complete for the most recent 2 years and should have a breakdown of the medical, indemnity and other expense categories

• Failure to address draft or final settlement agreements and court rulings

• Failure to provide records referenced in the MSA proposal or medical file

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April 10, 2025

CMS has an updated guideline regarding request for review after an MSA has been submitted.

When the following criteria are met, CMS will permit a one-time request for re-review :

• CMS has issued a conditional approval/approved amount.

• The case has not yet settled as of the date of the request for re-review.

• Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

• Request must include submission of a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release information, and a summary of expected future care

• When a re-review request is reviewed and approved by CMS, the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased.

Additional criteria may apply depending on case circumstances.    

Do you have questions about MSAs, how to value future medical care or posturing your cases for future medical settlement?  Contact us for more information!

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February 3, 2025

CMS “Zero MSA” Guideline update!

Effective July 17, 2025, CMS will no longer accept or review WCMSA proposals with a zero- dollar ($0) allocation. However, entities should consider the parameters below in determining whether a zero-dollar WCMSA allocation is appropriate and maintain documentation to support that allocation.

Although WC claimants must always protect Medicare’s interests, is the position of CMS that a WCMSA is not necessary under the following conditions because when they are true, they indicate that Medicare’s interests are already protected:

The individual's treating physician documents in medical records that to a reasonable degree of medical certainty the individual will no longer require any treatments or medications related to the settling WC injury or illness*; or

The workers’ compensation insurer or self-insured employer denied responsibility for benefits under the state workers’ compensation law and the insurer or self-insured employer has made no payments for medical treatment or indemnity (except for investigational purposes) prior to settlement, medical and indemnity benefits are not actively being paid, and the settlement agreement does not allocate certain amounts for specific future or past medical or pharmacy services as a condition of settlement; or

A Court/Commission/Board of competent jurisdiction has determined, by a ruling on the merits, that the workers’ compensation insurer or self-insured employer does not owe any additional medical or indemnity benefits, medical and indemnity benefits are not actively being paid, and the settlement agreement does not allocate certain amounts for specific future medical services; or

The workers’ compensation claim was denied by the insurer/self-insured employer within the state statutory timeframe allowed to pay without prejudice (if allowed in that state) during investigation period, benefits are not actively being paid, and the settlement agreement does not allocate certain amounts for specific future medical services.

NOTE: If Medicare made any conditional payments for WC injury-related services furnished prior to settlement, then Medicare will recover those payments. In addition, Medicare will not pay for any WC injury-related services furnished prior to the date of the settlement for which it has not already paid.

*The treating physician’s opinion that no future care is needed must be consistent with the medical record.  For example:  If a patient has been treating consistently for CRPS and has been on medications for CRPS longitudinally over time, CMS may reject the treating physicians recommendation that no further care is needed.